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CHAPTER 4

Individual Factors in Patient Teaching and Patient
Adherence

PSYCHOSOCIAL ISSUES IN PATIENT TEACHING
Patients with medical problems sometimes behave in ways that imperil their health. Some who have not yet
developed symptoms of disease neglect measures that might prevent it. Others with chronic conditions fail to
follow recommendations that would control their symptoms or that would prevent complications from occurring.
The fact that patients would purposely behave in a manner that would make them vulnerable to disease or that
would make their conditions worse seems totally irrational. It is widely recognized, however, that many patients
neglect to take medications as prescribed, resist restriction of activities as recommended, and neglect to follow
preventive measures.

If one of the goals of patient-centered teaching is to produce behavior change that helps patients to improve
or maintain their health, then poor adherence with recommendations may be viewed as a failure in patient
teaching. Such behavior can be frustrating and puzzling for the conscientious health professional devoted to
increasing positive health outcomes through patient teaching. Why would patients deliberately act in ways
deleterious to their health despite having received information indicating that they should behave otherwise?
Why, for example, would patients with emphysema continue to smoke regardless of knowledge of the
consequences of their behavior? Why do some patients neglect self-care even though they know they will be
incapacitated by their condition if it is left untreated?

There is, of course, no single answer. All patients, as individuals, have different reactions, experiences, and
motives that direct their behavior. Illness, or threat of illness, elicits many responses from individuals and their
families. At times, responses are helpful; other times, responses deter patients from following the prescribed
therapeutic regimen. In addition to patients’ knowledge, many other factors have an impact on their ability and
willingness to carry out recommendations. Psychosocial factors that can have a profound impact on patient
teaching and its effectiveness both in terms of a patient’s receptivity to information and his or her ability or
willingness to carry out recommendations include the patients’ psychological traits, past experiences, gender,
age, culture or ethnic background, systems of support such as their family or other social group, financial
circumstances, and physical environment.

Health professionals may be uneasy dealing with psychosocial factors, however. Some may be unaware of
signs that could alert them to factors with an impact on the effectiveness of patient teaching. Others may be
reluctant to act on psychosocial factors when they are identified. Some may believe that considering
psychosocial factors is impractical because of time constraints.

If patient teaching is to be effective, psychosocial factors cannot be avoided. Giving patients information
about their condition or treatment without considering factors that may facilitate or hinder their following
recommendations is not only an inefficient use of time, but also leads to poor patient teaching outcomes. If, for
example, the patient does not believe in taking medication, but medication is a necessary part of treatment,
ignoring the problem while continuing to teach the patient about the medication is useless. Explaining the
importance of treatment and how to take the medication does little good unless the health professional also
considers the patient’s beliefs and feelings and takes those factors into consideration.

In other instances, health professionals may avoid psychosocial factors because they seem overwhelming.
Psychosocial factors may be avoided because of the health professional’s own feelings of inadequacy in
handling the problems presented. Again, merely relaying information and failing to address psychosocial issues
is a futile effort. Without a firm understanding of the other factors that have an impact on the patient’s
receptiveness to information or his or her ability to follow recommendations, the health professional’s efforts in
patient teaching can end in frustration for both the patient and the health professional.

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Gathering information about and assessing psychosocial factors should be part of every patient interaction.
Health professionals need only be aware of available data sources, and identification of psychosocial issues
need not involve extensive use of time. Likewise, if health professionals put psychosocial information into the
right perspective, information need not be overwhelming, but rather can be helpful in working more effectively
with the patient.

Patients frequently drop hints about factors that might influence their ability or willingness to follow
recommendations. By listening to these hints and exploring them further, health professionals may be able to
devise a plan with the patient that will help them be better able to follow recommendations.

Take, for example, Mrs. Delengato, a 32-year-old woman with a history of rheumatic fever. Mrs. Delengato
was being treated for cardiac arrhythmias with several medications. The physician taught her about her heart
condition and gave her clear and explicit instructions about her medication and behavioral restrictions. At a
subsequent outpatient visit, however, it was noted that Mrs. Delengato frequently neglected to take her
medication and continued to smoke one pack of cigarettes a day despite recommendations to stop smoking.
During the clinic visit, Mrs. Delengato stated that she had recently experienced tachycardia, weakness, and
pressure in her chest. In the course of describing her symptoms, she mentioned that her mother had had the
same symptoms. Upon further exploration of her statement, Mrs. Delengato revealed that her mother had died at
age 35 from a myocardial infarction, although she had had no previous history of cardiac problems. As the
physician continued to talk with her, the patient revealed that she believed she was also destined to die at an
early age. Mrs. Delengato felt that if her mother had had no previous history of heart disease and still died, that
with her own history of rheumatic fever and subsequent health problems, there was little hope no matter what
she did. Consequently, Mrs. Delengato had elected to do what she wanted, feeling the medications and
restrictions were of little consequence. Because the physician had discovered this new information, he was able
to alter his approach to Mrs. Delengato and alter patient teaching to address her fears and beliefs.

Patients have a set of norms and values—expressed or unexpressed—that are individually determined by their
culture, socioeconomic status, ethnicity, gender, age, and life experiences. The meaning of illness and the
consequences ascribed to following or not following recommendations are based on patients’ values and norms.
Patients’ symptoms are also relative; whereas some may dramatize symptoms, others are passive in response
to their symptoms and conditions. Health professionals also have values and norms that direct their lives and
guide their practice; however, health professionals cannot assume that their particular way of viewing an illness,
issues of prevention, or the importance of carrying out treatment recommendations are shared by all patients.

Gaining an appreciation of patients’ life situations helps health professionals better identify and understand
patients’ beliefs, perspectives, and priorities. Only with this type of information will the health professional be
able to devise an effective teaching plan that is suited to the individual. Conducting patient teaching based on the
values and needs of the health professional, rather than on those of the patient, can result in patients rejecting
information as well as recommendations given. Once this has occurred, it is difficult to reinvolve patients.

Health professionals’ knowledge of psychosocial issues can be incorporated into patient teaching so that
factors influencing patients’ receptiveness to information and their ability and willingness to follow
recommendations can be taken into consideration. Health professionals may recognize the need to gather
additional information. Discovering additional psychosocial factors may serve as a prompt to refer the patient to
another health professional or agency for assistance, or the services of other health professionals may be
incorporated to help meet patient needs. Outcomes and expectations for patient teaching need to be negotiated
between patients and health professionals with the establishment of new goals and expectations tailored to
meet patients’ individual needs.

The greater the health professional’s understanding of psychosocial factors, the greater the chance that
such information can be incorporated into a more effective teaching interaction. As a result, there is an increased
probability that the patient’s ability to follow recommendations will be enhanced. Effective patient-centered
patient teaching uses creative techniques in which psychosocial factors are identified and incorporated. Each
patient is an individual; consequently, there can be no generalization about specific factors that affect all
patients. The health professional must become skillful, confident, and adept in assessing patients’ needs and
factors that have an impact on the degree to which they are willing or able to follow recommendations.

THE PATIENT AS AN INDIVIDUAL
Patients come to the patient teaching situation with different levels of knowledge and skill as well as different
beliefs about their illness. In addition to assessing an individual’s level of knowledge and skill, it is important to
assess attitudes, perceptions, and past experiences of patients as they relate to their current health status. Just
as all patients are unique individuals, the presentation of the same type of acute or chronic condition is highly
variable in different patients, and consequently so are their reactions to it.

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A variety of factors determine each patient’s reactions not only to symptoms and illness, but also to patient
teaching and recommendations provided. Because of this variability, health professionals sometimes find it
difficult to know how to approach patient teaching so that it is most effective. The better able health
professionals are to tailor patient teaching to the individual patient, the greater the likelihood that patients will be
able to follow recommendations given. Recognizing the individual needs and priorities of each patient helps
health professionals to present information in a way that is meaningful to the individual and will enhance their
ability to follow recommendations. Unless health professionals understand the patient’s perceptions of his or her
condition and treatment, the effectiveness of any patient teaching intervention as well as the level of adherence
with any treatment advice given will be seriously compromised (Gerteis et al., 1993).

Each patient has their own personality, individual method of coping with stress, a variety of past experiences,
and a system of beliefs about the world. Recognizing the individual needs and priorities of each patient helps
health professionals alter their approach to patient teaching as well as the information given. Recognizing
factors that can influence patient receptiveness to patient information increases teaching effectiveness.

For example, how patients perceive manifestations of a condition and the impact it has on them may vary
with their developmental stage in the life cycle. A skin lesion experienced by an adolescent may be devastating
because of their sensitivity about appearance, but a skin lesion in an older adult may be of concern because they
fear it could be cancer. The lesion may be similar and both patients may consult with a health professional about
the lesion, but each comes with a different concern and different expectations for outcomes. How the health
professional approaches the individuals in both instances can affect effectiveness of patient teaching. Even if
the lesion is similar in both cases, the teaching approach will be different because each patient has different
priorities and concerns.

Consideration must also be given to patients’ past experiences and expectations. Attitudes, values,
experiences, and life stresses all help formulate patients’ beliefs about health and illness and, to a large extent,
their receptiveness to information and acceptance of treatment recommendations (Rankin, Stallings, & London,
2005). For instance, a pregnant teenager whose mother had no prenatal care and no resulting complications from
pregnancy may see little need for regular visits to the physician during her own pregnancy. The patient who is
accustomed to receiving antibiotics routinely for sore throats regardless of the cause may have some difficulty
understanding why the physician is only giving instructions about gargling with salt water.

The way individuals perceive their condition and symptoms, and the degree to which they act on seeking
information or following recommendations are also unique to each individual and their beliefs about health and
illness (Mechanic, 1961). Some believe that health and illness are predetermined and that they have little control
over health outcomes. They may assume a “what will be, will be” attitude, feeling they have little control over
whether they develop an illness. In some instances, they may not believe they are susceptible to the disease in
question, and that they will be immune to consequences of their behavior, even though those behaviors have
been shown to contribute to the development of disease. For instance, an individual may scoff at preventive
practices such as stopping smoking because they saw their grandfather smoking all his life and still living to a
ripe old age.

Another critical factor to consider in patient teaching is the meaning patients attribute to their condition. How
the patient assesses the symptoms and/or consequences of a disease or health behavior in terms of
significance and importance all play a part in the degree to which patients receive information and incorporate
recommendations. Despite a patient’s knowledge or skill acquisition, medical management and patient teaching
may be extremely difficult if he or she has not accepted the condition or its seriousness, if he or she views it as a
means of controlling others or of punishing themselves or others, or if he or she has a variety of other detrimental
feelings about their condition.

To illustrate the importance of meaning associated with a particular condition, take the case of Mrs.
Yablonski, who was seen in the neighborhood health clinic because of severe hypertension. The clinic nurse,
aware of the importance of patient teaching, spent considerable time with Mrs. Yablonski, explaining
hypertension, the particular treatment prescribed, how the medication was to be taken, and the possible
consequences of not taking it properly. Being very conscientious, the nurse evaluated Mrs. Yablonski’s
understanding of her condition and treatment recommendations, and was delighted to find that she was able to
describe her condition and treatment in detail, as well as why the medication was important, and what might
happen if her condition was left untreated. No other barriers to following recommendations, such as inability to
purchase the medication, were identified. The nurse felt that the teaching session had been effective and felt
certain that Mrs. Yablonski would be extremely dedicated to following recommendations.

Mrs. Yablonski was seen at the clinic weekly for blood pressure checks, but each week her blood pressure
remained elevated. The physician at the clinic continued to add antihypertensive medications to her treatment
regimen, until at last it was decided that she should be referred to a nephrologist for further evaluation. Mrs.
Yablonski had been at the referral center for about a week when the nephrologist called her physician, saying

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that all her tests had been negative and that her blood pressure was currently being controlled on one medication.
Upon questioning Mrs. Yablonski closely, the nephrologist had found that she had not taken any of the
medication prescribed by her physician. When Mrs. Yablonski returned to her regular physician, he questioned
her, puzzled as to why she would deliberately not take her medication when she had understood the possible
consequences of stroke and even death from her lack of adherence with the regimen. Mrs. Yablonski replied that
she viewed her hypertension as deserved punishment for indiscretions she had committed in the past and
therefore was accepting the consequences as “payment” for her previous behavior.

Mrs. Yablonski’s severe guilt, as described in the example, would warrant counseling and therapy that were
beyond the scope of patient teaching. However, had either the physician or nurse been aware of Mrs. Yablonski’s
attitudes about her condition earlier, appropriate referral for counseling could have been made, and an exposure
to a potentially dangerous situation could have been avoided. In addition, a needless expenditure of time, effort,
and money could have been saved. Had the physician or nurse developed a relationship with Mrs. Yablonski that
enabled her to share her feelings, the situation also might have been avoided. By referring Mrs. Yablonski to the
appropriate health professional for the help she needed, the patient teaching intervention might have had a more
successful outcome.

In this instance, Mrs. Yablonski’s attitudes, not her level of knowledge, were the determinant of the degree to
which she followed the physician’s recommendations. Had her attitudes and the meaning she attributed to her
condition been identified, counseling and support could have been recommended that could help her resolve her
feelings, and consequently could have made patient teaching efforts more effective.

SOCIAL INFLUENCES
We are all part of a social group, whether it consists of family, friends, culture, or a religious group. Each group
establishes its own norms or values to which individuals within the group are expected to subscribe and adhere.
Deviation from these values or norms can be the source of ridicule from the group or, in some cases, even
expulsion. Consequently, when conducting patient teaching, it is also important to consider the patient’s system
of social support, the attitudes and beliefs of the patient’s social group, and cultural and religious influences that
may impact on patient’s receptiveness to information or ability or willingness to follow recommendations.

Social groups provide a sense of self and give individuals a framework within which to interpret various
aspects of life and ways of responding to a variety of events. Values of health and health care, the meaning of
illness, and which treatments are deemed acceptable or unacceptable are learned within the social group.

Patients and health professionals frequently come from different social groups and therefore may have
different values, beliefs, and assumptions. Those differences may emerge not only with regard to reactions and
interpretations of various life events but also with regard to health and health care in general. If health
professionals make the assumption that everyone subscribes to the same values they do, or if differences in
values between health professionals and patients are not identified, there is a basis for misunderstanding as
well as a barrier to communication.

The influence of social groups is extremely relevant to patient teaching. Without an understanding of the
influence of these groups, health professionals can spend much effort conducting patient teaching that is
irrelevant, or at times offensive, to patients who have values different from their own. Patients will not only be
unwilling to follow recommendations that conflicts with their own beliefs or values but may also be alienated
from consulting with the health professional in the future. Consider the case of Mrs. Taylor.

Mrs. Taylor had just delivered her fifth child. The postpartum unit of the hospital had established a regular
patient teaching session for all patients who had delivered. Part of the program consisted of a module on
contraception. The nurse proceeded to teach Mrs. Taylor about contraception according to the teaching protocol.
She observed that Mrs. Taylor appeared to be more withdrawn as the teaching went on. The nurse interpreted
this to mean that she was tired and concluded the session, asking Mrs. Taylor if she had any questions about the
information. She also mentioned that she would come back at a later time to continue the teaching session. Mrs.
Taylor replied that she had no questions and that it would not be necessary for the nurse to return. Puzzled, the
nurse left the room, charting that Mrs. Taylor was uncooperative and resistant to patient teaching. Had the nurse
taken some time before the teaching session began to gather some information about Mrs. Taylor as an
individual, she would have learned that the woman was a devout Roman Catholic who was very much opposed to
birth control. Not only had the nurse not considered the patient’s needs when conducting the teaching
intervention, she had created a barrier to further teaching as well. The nurse’s time was wasted, and the
opportunity for future teaching was lost.

Other instances of the influence of social groups may be illustrated by various patients’ use of folk remedies
or folk healers. Folk remedies endure in various areas of the United States because they are well-known, trusted,
accessible, and inexpensive. Advice about folk remedies passed down through generations by trusted individuals

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is often perceived as more helpful than prescribed medical treatments. Recommendations may be distrusted
when given by a health professional whom the patient does not know, and with whom he or she has insufficient
rapport. In other instances, prescribed treatments may be expensive and/or distasteful and may not give the
immediate results the patient expects.

In some cultures, folk healers are still intermingled with modern medicine. It does little good to try to discredit
folk remedies or the advice of folk healers that has been given to the patient. The folk healer may be a trusted
part of the patient’s healthcare system. Efforts to discredit such healers or the advice given by other trusted
members of the patient’s social group may only alienate the patient, who may distrust the health professional in
the first place. It may be far better to identify the folk remedies tried by the patient or recommended by the folk
healer and add medical technology to them rather than demanding that the patient abandon them altogether. At
times, the consequences of folk practices may be somewhat difficult to deal with, especially if they can cause
harm. Such a situation is illustrated in the case of Mr. Romaro.

Mr. Romaro, a patient of Filipino-American background, was seen at a family practice center for epigastric
pain. After a number of diagnostic tests, the physician diagnosed him as having an ulcer and immediately
prescribed a regimen of medication and a restricted diet. Mr. Romaro was referred to the dietitian for diet
counseling, during which the diet and its purpose were explained. Sometime later, the patient returned to the
clinic with severe worsening of symptoms. On evaluation, the physician indicated that surgery might be
necessary and admitted Mr. Romaro to the hospital for further observation. The dietitian who had conducted the
original diet teaching visited Mr. Romaro in the hospital. In the course of the conversation about the extent to
which he had followed the prescribed diet and treatment regimen at home, Mr. Romaro revealed that he had not
taken the medication and had disputed the dietitian’s advice to avoid spices in his food. In the Filipino culture,
spices were actually considered to have healing properties. Obtaining a variety of spices from his grandmother,
the patient had proceeded to spice his food liberally. When his condition became worse instead of better, he
attributed the worsening to the prescribed treatment and discontinued it.

Such situations are indeed difficult to work with. In this case, the patient’s beliefs and folk remedies were the
cause of potential harm. Had the dietitian recognized these beliefs in the initial teaching interaction, they could
have at least been considered. The situation might have been different had the dietitian been alert to the
possibility of culture differences rather than conducting teaching in a standardized manner. The dietitian might
have taken the time to ask Mr. Romaro about his beliefs and perceptions. The dietitian might have said: “I know
very little about the Filipino culture. I find sometimes even when Americans are born in this country, the traditions
of our heritage, of our grandparents and great-grandparents, are still important to our own lifestyle. Are there any
special things that we’ve talked about with regard to your diet that are contrary to any of your cultural or personal
beliefs?” Additional information about multicultural issues is addressed in Chapter 7.

To discount patient beliefs completely only creates a barrier to establishing trust in the future. To correct
erroneous beliefs or to criticize advice given the patient by well-meaning friends or relatives destroys trust and
rapport. In such instances, it is far better for health professionals to identify the beliefs and health practices of
patients, and to work within the patient’s framework to build a stronger relationship for the future. Rather than
arguing with beliefs, the health professional will be more successful and effective if the patient’s beliefs are
considered and incorporated into the teaching plan.

Social influences also impact patients’ feelings about appearance. In the United States, being slender is
considered an attractive attribute. Many take the saying, “You can never be too thin or too rich,” quite seriously. It
is quite easy for health professionals to assume that all patients view obesity as undesirable, not only in terms of
appearance, but also in terms of health. Not all cultures hold similar views, however. In many cultures, eating
occupies a central role in life. Overweight may actually be viewed as attractive, with obesity a sign of health and
prosperity. In some cultures, food may be equated with love and affection.

In these instances, talking with patients about weight control and its importance may disavow their own
perceptions and beliefs and set the stage for failure. If health professionals view obesity as a health threat, it is
far more important in the initial teaching session for the professional to assess what eating means to the
individual and to begin working with the patient at that level. If the patient’s beliefs about weight appear firmly
ingrained, it may be better to begin talking with them about other means of prevention or other aspects of the
medical regimen than to attack their basic views. On the other hand, if the patients see eating as a source of
comfort and solace or a way of dealing with stress, health professionals may gradually incorporate their views
into the discussion, helping them recognize other ways of coping and reducing stress.

The patient’s family and peer group are important social groups that have considerable influence over the
patient’s ability and willingness to carry out medical recommendations. Even if the patient has sufficient
knowledge, skill, motivation, and attitude to carry out the treatment recommendations, the patient’s family or peer
group can have a profound impact on the extent to which he or she actually follows health advice. It would seem,
for instance, that a patient who has solicited advice about weight control, been counseled accordingly, and

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appears to have an understanding of the diet regimen would have an excellent potential for success. Surely, the
healthcare professional would have every reason to believe that teaching would be effective. However, if the
family considers obesity attractive and criticizes the patient’s efforts to lose weight, without additional
counseling and support, the patient may fail to reach his or her goal. In many instances, the health professional’s
best teaching efforts are undermined if the family does not understand the condition for which the patient is
being counseled, or the importance of treatment itself, if medical recommendations conflict with their beliefs.

On the other hand, family and friends can also be a great support and can reinforce the patient’s effort to
maintain the prescribed treatment or recommendations. Families who offer support of the patient in following a
treatment regimen are tremendous aids in helping the patient adhere to recommendations.

The importance of understanding the individual patient and the significance of the influence of the social
group, especially family or peers, can be illustrated by the case of Ms. Elkins, …

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that had already begun. She then began to describe the disease process of diabetes, explaining why insulin
was important in its treatment. Ms. Elkins fiancé had had limited previous understanding of diabetes. Neither had
he had a firm understanding about the role of insulin and the consequences of non-adherence to the prescribed
dosages. He was encouraged to help Ms. Elkins become emotionally strong and calm to help reduce the
chances of her developing complications. He was also helped to understand that taking insulin was a very
important part of helping Ms. Elkins reach this goal.

The beliefs, attitudes, and values of a variety of social groups have a tremendous impact on patients and
must be taken into consideration in planning and conducting patient teaching. Just as it is important to consider
these variables, and especially those related to the patient’s social group in terms of culture or ethnic
background, it is also important not to overgeneralize about the patient’s social group. Even within the United
States, there may be differences between groups of the same ethnic origin, depending on where in the country
members were raised. Likewise, there are differences between persons of various ethnic backgrounds who
were raised in the United States and those raised in the country of origin. As with all social groups, each member
is still an individual, with a personal makeup and past experiences that make him or her different from every
other member of the group. Each patient must still be considered uniquely individual. The key is to gather
information about each individual to determine his or her values, beliefs, or perceptions and to translate those
values, beliefs, or perceptions into patient teaching.

ENVIRONMENTAL FACTORS
A variety of factors within patients’ environments can also influence how effective patient teaching will be.
Factors such as patients’ geographic location, their living arrangements, financial status, daily schedule, or type
of employment can all influence the extent to which they are willing or able to carry out recommendations.
Factors that facilitate or impede patients’ following recommendations may include the physical environment, the
work environment, their schedules, or the personal lifestyles they have adopted. Even when patients have
sufficient and appropriate knowledge, proficient skills, appropriate attitude, and strong support, unless obstacles
within the environment that may interfere with adherence to recommendations are identified, patient teaching
may still be less than effective.

When environmental factors contribute to nonadherence, the issue may not be a function of unwillingness or
inability to follow recommendation, but rather a result of lack of knowledge of how changes could be made so
that the recommendations could be followed. In these instances, part of patient teaching must be directed
toward helping patients devise a plan whereby recommendations can be followed despite environmental
limitations.

Such was the case of Ms. Knoll, an elderly patient who lived alone in the same farmhouse where she had
been born. Because of symptoms she had been experiencing, she sought advice from the physician practicing in
a small town several miles from where she lived. After examining Ms. Knoll, the physician ordered a variety of
tests, one of which necessitated the collection of a 24-hour urine specimen that would have to be refrigerated.
The physician carefully explained the tests to Ms. Knoll, how she should prepare for them, and why they were
being ordered.

In concluding patient teaching, the physician asked Ms. Knoll if she felt she would be able to carry out the
preparations for the tests, or if she felt there were any problems that would make preparations difficult for her.
Ms. Knoll replied that she felt there were several problems. First, transportation was difficult for her because she
did not drive and was, therefore, dependent on her niece or neighbors to take her places. Although they had
always been very willing to help her, the tests were scheduled at such an early time that she was reluctant to ask
them. She continued that she had never had electricity put into her farmhouse and, consequently, had no means
of refrigerating the urine specimen even if she was able to collect it. After the physician was made aware of Ms.
Knoll’s situation, the physician began to help her find alternatives and resources that would enable her to have the
tests. Because environmental factors were identified early, diagnostic procedures and understanding
subsequent treatment were not delayed, and the physician’s original efforts at teaching were not wasted.

Patients must sometimes be helped to identify strategies that would enable them to follow
recommendations. Telling a person who has had a myocardial infarction to avoid going up and down stairs can
be unrealistic for the patient whose bedroom and only bathroom are on the second floor. Patients’ ability and
willingness to follow recommendations will be much greater if the health professional identifies environmental
restrictions and teaches patients how to modify their environment appropriately.

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Other barriers that may affect adherence may arise from patients’ work or home environments in terms of
lifestyle or responsibilities in their daily lives. For example, it is unrealistic to expect a prenatal patient with
symptoms of preeclampsia to maintain full bed rest when she has several other preschoolaged children at home
as well. To maximize the possibility that she will adhere to advice, the health professional must explore with the
patient the possibility for provision of childcare during the day while her husband is at work. Likewise, a patient
whose occupation involves considerable bending and stooping may not be able to follow advice to avoid bending
and stooping altogether. It may be far more profitable, in terms of effectiveness and efficiency, to teach the
patient proper body mechanics when stooping or bending, or to help the patient identify alternative methods for
accomplish tasks, which may minimize bending and stooping.

THE NATURE OF TREATMENT RECOMMENDATIONS
At times, even though the patient may be receptive to information and may fully intend to carry out
recommendations, factors in the recommendations may become cumbersome, noxious, or burdensome in other
ways that eventually impact on adherence. The nature of treatment recommendations alone can interfere with a
patient’s ability and/or willingness to comply with the prescribed treatment. Complexity of the treatment regimen,
frequency, and duration of treatment have all been linked to adherence (Dunbar-Jacob, Burke, & Puczynski, 1995;
Wing et al., 1986). The more treatments or medications prescribed, the more adverse the effect on patient
adherence (Vollmer, 1998). Adherence with the treatment recommendations also decreases with the length of
time it must be carried out (Rosenstock, 1988). Although side effects may not affect patient adherence in all
instances, from a practical standpoint, it makes sense that a patient experiencing unpleasant side effects from
a medication or treatment may be prone to discontinue the regimen (Spiker, 1991), and in some patient
populations, side effects can be a major contributor to nonadherence (Harris, 2008). In other instances, patients
may be unable to take medications in their prescribed form. For example, a patient may have difficulty swallowing
pills but be able to take a liquid form of the medication. If the patient’s inability to take the medication in pill form
is not identified, however, the patient may elect to discontinue the medication without telling the health
professional.

In areas of diet, exercise, or other lifestyle changes, patients may find the regimen too difficult, too time
consuming, or too unpleasant to follow. Health professionals can greatly enhance the chances that patients will
follow recommendations by exploring their perceptions of the recommendations and their ability and/or
willingness to carry them out.

INFLUENCE OF DIFFERENT PERSONALITY STYLES
Personality has been defined as the underlying cause of individual behavior and experience within a person
(Cloninger, 2008). Each patient has a unique personality style, which includes a combination of traits and
characteristics that determines how they interact with others, how they respond to experiences, and how they
make decisions. These characteristics can predispose individuals to certain emotional states, affect their
reaction to various situations, determine coping strategies for stress, and subsequently affect behavior (Lazarus,
1966).

Although a number of individual factors affect patients’ receptivity to information and the degree to which
they will adhere to treatment recommendations, their basic personality plays a large role as well. The outward
manifestations of personality in terms of behavior are a reflection of the individual’s internal mental state.
Individual personality characteristics give individuals some degree of consistency and predictability regarding
their behavior. Personality traits, to some extent, determine which aspect of illness individuals may find anxiety
provoking and which techniques they will employ for coping with their anxiety.

Some personality traits exhibited by patients can be very frustrating for the health professional unless they
are recognized as such and consequently taken into consideration when working with patients. The more aware
health professionals are that some behaviors patients exhibit relate not only to their reaction to illness but also to
their basic pattern of behaving in a nonillness state, the better they will be able to tailor their teaching methods to
the individual patient so that it will be most effective.

Take, for example, Ms. Lee. Although she frequently demanded information, direction, and support from Dr.
Franklin, she rarely followed the recommendations given. She appeared to be impulsive and unpredictable,
praising Dr. Franklin’s teaching efforts on some occasions and devaluing them on others.

Patients such as Ms. Lee can be very demanding and produce feelings of anger and frustration in the health
professional who is trying to conduct patient teaching. This type of behavior may, however, merely be a reflection
of the patient’s basic personality style and its manifestation as a reaction to illness. Ms. Lee, in demanding
information and support, may be expressing a need for security and reassurance that Dr. Franklin will continue to

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be there for her. Ms. Lee’s case illustrates potential conflict that many patients experience in which they desire
the health professional to rescue them and, at the same time, fear that the health professional will desert them.

Luckily, Dr. Franklin took time to look at Ms. Lee’s behavior objectively, rather than personally, and, in an
attempt to discover techniques that would help him to work more effectively with Ms. Lee, he discovered that by
using gentle but firm limit-setting, Ms. Lee responded by becoming more cooperative and easier to work with.

Another personality type may be illustrated by the example of Mr. Boyce, who had been diagnosed as having
hepatitis. The nurse, Mr. Morgan, became increasingly annoyed when trying to conduct patient teaching with Mr.
Boyce, who seemed preoccupied with trivial details, seeking more and more information and, at the same time,
being rigid and indecisive. Mr. Boyce became extremely upset at any variation in routine and became very
demanding in his expectations of Mr. Morgan. In discussing his difficulty in working with Mr. Boyce with his
colleagues, it became evident to Mr. Morgan that Mr. Boyce was desperately struggling to maintain a sense of
control in light of an illness he viewed as threatening. With this insight, Mr. Morgan changed his approach to Mr.
Boyce, offering a more methodical approach to patient teaching and engaging Mr. Boyce in fuller participation.

Mr. Williams illustrates yet another example of personality style. He seemed very flamboyant with
exaggerated emotions. He had been scheduled for coronary artery bypass surgery. The nurse, Ms. Applebaum,
had been assigned to conduct the preoperative teaching. It became very difficult for Ms. Applebaum to conduct
the teaching session because Mr. Williams seemed to have little interest in understanding the procedure, stating
very dramatically that he just wanted to have the procedure done and over with. Ms. Applebaum talked with Mr.
Williams’ family physician in an attempt to gain some insight into Mr. Williams’ reaction that might enable her to
conduct patient teaching more effectively. She discovered that Mr. Williams appeared to need much attention
and reassurance of his physical prowess. Consequently, when she returned to the teaching situation, she offered
reassurance regarding his postoperative course and offered him an opportunity to express his own fears about
the procedure and consequences.

Some patients are, by nature, suspicious and mistrustful. When such individuals become ill, these traits may
become exaggerated so that every question, procedure, or recommendation is closely scrutinized, and motives of
the recommendations questioned. Although such hypervigilance on the part of patients can be annoying to health
professionals who, during patient teaching, are asked to justify everything, by attempting to understand patients’
viewpoints, being supportive, and keeping some interpersonal distance, health professionals can maintain
objectivity and conduct patient teaching more effectively.

PATIENTS’ SELF-VIEW
Patients’ psychological makeup is multidimensional, and various dimensions impact how patients view
themselves in the context of health and illness. The more health professionals know about individual patients,
the more this knowledge can be used to customize patient teaching. When patient teaching is tailored to the
individual patient, the more likely it is that the intervention will be effective. Learning about how to best approach
individual patients does not always have to be a time-consuming process. Considerable information can be
gained from simply listening closely to patients’ statements and observing their behavior.

Self-Identity
How individuals view themselves is linked to various factors; however, one factor is their self-identity, or how
they categorize or define themselves in a broader context. Individuals may have several categories of self-
identity, such as cultural identity, religious identity, gender identity, family role identity, or occupational identity, to
name a few. Whether the patient’s self-identity is as a professional, homemaker, neighbor, or a number of other
labels patients may use in their own self-description, it is important for health professionals to know what the
patient’s self-identity is and to utilize this information in patient teaching. If, for example, the patient’s self-
identity is tied to his or her role as a business executive who is capable of handling considerable responsibility
and making decisions, placing them in a dependent, passive role during patient teaching would most probably
decrease the likelihood of teaching effectiveness and may even alienate the patient. Or, if a patient’s identity is
strongly linked to cultural heritage, regardless of citizenship, knowledge of the patients self-identity can help the
health professional utilize that information in how they conduct patient teaching. For instance, a patient
appearing to be from the Pacific Rim, but who was born and educated in the United States and speaks perfect
English, may still have a strong cultural identity based on the heritage and influence of their parents and
grandparents, with associated customs or taboos.

Self-Esteem

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Another factor involved in how individuals view themselves is their self-esteem, or how much they like
themselves. Self-esteem is linked to the individual’s sense of self-worth and value, or how positively or
negatively they view themselves in relationship to others (Blascovich & Tomaka, 1991) or how well patients like
themselves and feel that others like them. Although research studies have shown little association between self-
esteem and health behavior (Baumeister et al., 2003), the relationship between self-esteem and psychological
well-being—including depression, anxiety, and alienation (Blascovich & Tomaka, 1991)—have definite
implications for patient teaching. Individuals’ degree of self-esteem determines how much confidence they have
in themselves and their abilities, as well as how capable they believe they are in handling certain situations and
performing certain tasks (Bernard et al., 1996).

Illness alone can lower an individual’s self-esteem. When individuals already have low self-esteem, illness
may contribute to lowering self-esteem further. Individuals with low self-esteem may have little confidence in
their ability to learn new material or new skills and may seem overdependent on others. When health
professionals are aware of and sensitive to a patient’s lack of self-esteem, they can use this information in the
patient teaching situation to make the intervention more effective.

Take, for example, Mrs. Sanders, a 78-year-old woman who had broken her hip, had surgical repair, and had
done well in the postoperative period. The nurse, Ms. Friedman, in preparation for Mrs. Sanders’ discharge, came
to her room to begin patient teaching about her management at home. Although Mrs. Sanders was alert and
seemed capable of understanding the information, she told Ms. Friedman that she must wait until her daughter
arrived because she probably would not be able to comprehend the directions anyway. When Mrs. Sanders’
daughter came, Ms. Friedman proceeded to give them both the information but found that Mrs. Sanders
repeatedly made self-deprecating remarks, such as, “I’m just too stupid to understand” and, “I never could do
anything right.”

After the teaching session, Ms. Friedman spoke with Mrs. Sanders’ daughter and learned that Mrs. Sanders
had always been self-critical and had a poor opinion of herself and her abilities. Ms. Friedman used this
information in her next teaching session with Mrs. Sanders, making a special effort to compliment Mrs. Sanders
and to reinforce her performance. In so doing, Ms. Friedman was attempting to build Mrs. Sanders’ self-esteem
and also her self-confidence, both of which would be necessary if she was to participate in her own self-
management at home and if the patient teaching intervention was to be effective.

Self-Efficacy
Self-esteem is linked to self-efficacy, the degree to which an individual believes they have control over events in
his or her life. Some people believe that most of what happens to them is determined by outside forces, and that
they have little control over their own destiny. Such individuals usually have a fatalistic view, which may be
demonstrated by statements such as, “I suppose I’ll try to follow the recommendations, but no matter what I do,
it probably won’t do any good anyway. Some things are just meant to be.” Other people believe that they have
considerable control over their lives and believe that their own actions can, at least in part, determine their
destiny. Statements such as, “Even though it’s hard to stay on a low cholesterol diet, I know if I want to be around
to see my grandchildren grow up, I’d better stick to the diet” are indicative that the patient believes that his or her
actions do, at least to some degree, have a relationship to health consequences.

Self-Concept
Self-identity, self-esteem, and self-efficacy are all linked to the individual’s self-concept. Self-concept involves
not only how individuals view themselves but also their perception of how others view them. Self-concept can
have an impact on both the individual’s receptivity to patient teaching as well as their willingness to follow
recommendations. Self-concept is usually consistent with an individual’s attitudes, experiences, and behaviors.
If information presented to the patient, or the recommendations given, are in conflict with the individual’s self-
concept, his or her level of involvement in patient teaching and level of adherence will likely be affected. Take for
example, Mr. Jones. Mr. Jones had been a powerlifter since high school, winning many regional and state
championships. He continued in college and as an adult, competing in various weight lifting events. Mr. Jones
viewed himself as strong and proficient, as did many of his friends and colleagues. At age 30, on the way to a
competitive weight lifting event, Mr. Jones was in a motor vehicle accident, which resulted in severe
musculoskeletal injury. After an extended period of hospitalization, the physician advised Mr. Jones that because
of his injuries he would need to end his career as a weight lifter, but prescribed a course of rehabilitation that
would enable Mr. Jones to regain mobility and function for most day-to-day activities. Rather than fully
participating in rehabilitation in order to get back to normal as soon as possible, Mr. Jones became fearful, angry,
and frustrated, refusing to participate in many of the rehabilitation activities. His self-concept as a strong,

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capable man had been firmly entrenched in weight lifting. Without that activity, his self-concept had been
shattered. Consequently, his altered self-concept caused significant setback in the rehabilitation process.

Whether or not health professionals share their patients’ views, ignoring their views or attempting to argue
with them about their views makes the patient teaching interaction less than effective. A better approach is for
health professionals to use this knowledge to make the teaching interaction more effective. If, for example, an
individual believes that he or she has little control over his or her health, rather than making the patient more
dependent, or arguing and barraging the patient with statistics regarding risk behavior, the health professional will
probably be more effective in identifying some immediate concerns, establishing some short-term goals, and
helping the patient experience some control and results from accomplishing the goals.

PATIENTS’ ADJUSTMENT TO ILLNESS
The onset of chronic illness can have major impact on physical, psychological, social, economic, and
recreational aspects of an individual’s life. Illness usually elicits some type of response in patients. These
responses, which are highly individual, are influenced not only by the personal experiences and beliefs of the
individual, but by those of others and of society at large. Patients differ remarkably in their perceptions of, and
reactions to, what may appear to be similar medical conditions. Although some patients react mildly to a disease
or condition that might devastate others, others may react with significant emotional and physical discomfort to
conditions many people would consider minor. Individuals also vary on how susceptible they believe they are to
disease and illness and, consequently, on how they perceive advice about preventive health measures.

Obviously, a variety of psychosocial factors determines individuals’ reactions to illness and, consequently,
their reactions to recommendations and advice given. Each patient’s perspective on health, illness, and medical
care itself is based on their self-identity, self-esteem, self-efficacy, and self-concept, as well as their
developmental stage and life situation. Before health professionals can conduct meaningful patient teaching
resulting in positive patient teaching outcomes, there must be a clear understanding of patients’ perceptions
about their illness, its meaning, and what they have as goals for the future.

When individuals become ill, their view of themselves changes. Patients’ reactions to the fact that they are ill
or could be ill involve their attitudes toward illness, how they interpret symptoms of illness, and their attitudes
about health care. Their perspectives will determine how willing or able they are to listen to health
recommendations and to follow them.

Health professionals frequently assume that patients seeking health advice are motivated to follow
recommendations in order to get well or stay well. However, if patients believe that no matter what they do they
cannot get well, it is unlikely that they will follow recommendations they consider to be of no benefit. In other
instances, health professionals may assume that the reasons patients are seeking health advice is because of
the symptoms they present. This may not always be the case. Symptoms patients present may be an entrée to
access health advice for other issues that the patient may feel reluctant to bring forward, or other issues may
overshadow the concern patients have for presenting symptoms. Recommendations given for conditions or
symptoms that are not of primary concern to the patient have less chance of being followed accurately.

For example, Mrs. Connors sought help from her physician with regard to weight control. She was referred to
a dietitian for dietary counseling and regular follow-up visits to monitor her weight loss. Mrs. Connors failed to
keep her follow-up appointments. When she was next seen by her family physician several months later for an
unrelated problem, it was noted that she had failed to lose any weight. Had the physician and dietitian listened
closely to Mrs. Connors’ needs, they might have recognized that although weight loss was Mrs. Connors’
presenting problem, her concern about her blood pressure actually seemed more pressing. Mrs. Connors’
unspoken concern was her blood pressure because she had a friend who had recently suffered a stroke.
Consequently, Mrs. Connors had done extensive reading on the subject and discovered that obesity was linked to
high blood pressure and stroke. After visiting the physician, however, and finding that her blood pressure was
normal, it was no surprise that she did not comply with the physician’s or dietitian’s recommendations. In Mrs.
Connors’ view, because her blood pressure was normal despite her obesity, the recommendations for weight loss
made little sense.

Health professionals may assume that patients who are sick are naturally motivated to follow
recommendations that will help them to get well. Patients’ response to illness and their associated behaviors,
however, may not always be consistent with this philosophy. How individuals respond to illness is dependent not
only on their personal characteristics and life situation, but on the reactions of others.

Although there are a number of explanations that have been developed to try to explain patients’ reaction to
illness, Parsons introduced the concept of the sick role in 1951. Parsons noted that the sick role itself is of a
mixed nature, and described the sick role with the following characteristics:

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•      Individuals are not viewed as being in power to overcome being sick by themselves; some therapeutic
process is necessary for patients to recover.

•      While patients are ill, they are not expected to function in their normal role or to perform their regular
obligations.

•   Patients are expected to want to get well.
•      Patients are expected to seek help for their illness and to cooperate with health professionals in their

attempts to get well.

Although there are a number of other explanations of why people behave as they do when confronted with
illness, some aspects of this model may apply to certain individuals. People who are ill are generally excused
from social responsibilities. For instance, people are usually not expected to come to work when they are sick;
individuals are excused from school because of illness; an individual would not usually be expected to host a
social event or attend a meeting when they are ill. Although people are excused from activities when they are ill,
they are also usually expected to take some responsibility for their recovery, such as seeking medical treatment
or engaging in behaviors that will help them recover. Most people do not want to be sick and most do not view the
sick role as a positive role to occupy. Therefore, many patients will be self-motivated to get better and will be
encouraged by others to participate in activities that facilitate their recovery. For some individuals, however, if
they are dissatisfied with the social role they occupy, they may view the sick role as preferable. These patients
may be less motivated to follow recommendations that would help them recover and return to their former social
role and obligations. In these instances, illness legitimizes a dependency that they enjoy, or brings them attention
they desire from others. In these instances, a patient’s

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motivation to retain his or her sick role may be greater than the motivation to get well. Although he or she may
engage in the socially acceptable behavior of seeking medical advice, he or she may sabotage the treatment
plan by not following recommendations. In some instances, patients may vacillate between their wish to be
independent and get well and their wish to remain ill and be taken care of.

In the framework of the sick role model as described by Parsons, not fully participating in efforts to get well
is socially unacceptable. Consequently, nonadherence may not be easily recognized and can be subtle. Take, for
example the case of Mrs. Jensen, a part-time seamstress who had begun experiencing numbness and tingling in
her thumb. Her physician diagnosed mild carpal tunnel syndrome, prescribed anti-inflammatory medications and
wrist splints, and encouraged her to modify her sewing activities so as not to aggravate the condition further.
Mrs. Jensen filled her prescription, and from all indications appeared to be taking her medication as
recommended. She always appeared at the physician’s office wearing the wrist splint and told the physician she
had given up her part-time seamstress position. Mrs. Jensen’s family pitched in, helping her do housework, and
neighbors brought food over frequently so Mrs. Jensen would not have to strain her hand by cooking Although
from all outward appearances it appeared that Mrs. Jensen was fully participating in her treatment, she
continued to sew in her spare time, an activity she did not inform her physician of, nor an activity of which her
family was aware.

Illness itself may be used for coping with personal problems. Mr. Wilson had recently graduated from college
with a degree in secondary education. Shortly after taking his first job in a secondary school, he developed flu
symptoms and severe congestion. Consequently, he was advised to stay at home for several days. Although Mr.
Wilson sought medical care, received a prescription for medication, and had been advised to rest at home, he
continued to appear at school, walking there in bad weather, staying for a few hours, and then returning home. He
neglected to pick up his medication at the pharmacy until several days after his visit with the physician, saying
that he was too ill at the time to go to the pharmacy. The symptoms became progressively worse; Mr. Wilson
continued his routine of performing his tasks at school in a perfunctory way and then returning home. He
continued to seek medical care for his continuing symptoms. After several visits to the health clinic, the nurse
began to note that although Mr. Wilson appeared consistent in keeping his appointments, he did not appear to be
following any of the other recommendations that, presumably, would help him recover at a more rapid rate. In
talking with Mr. Wilson before the appointment, the nurse questioned him about his job. Through their discussion,
the nurse noted that although Mr. Wilson stated that he was happy with his work, he also appeared rather vague
and uncomfortable when talking about how he perceived his level of performance. Through further discussion
with the physician, the patient later revealed that he was quite unsure of his ability to perform in the classroom
setting. Because of his illness, expectations about his performance were lowered, both by students and his
peers. In addition, Mr. Wilson was actually somewhat martyred by coming to school despite his illness.

Health professionals may not be able to immediately determine patients’ levels of motivation to get well or to
remain sick. Although there may not be a conscious motivation on the part of the patient to stay in the sick role, it
behooves health professionals to be aware of the possibility and how, in turn, the impact such unconscious
motivation can have on patient teaching and adherence. Astute observation and deduction can help health
professionals identify patient motivation level, and give the health professional the opportunity to begin open
discussion of patients’ feelings and fears, so that other ways in which patients needs can be met can be
determined.

Patients’ responses to illness may also relate to their life circumstances. Economic consequences of illness,
both acute and chronic, can have an impact on patient receptivity to patient teaching and, subsequently, on
adherence with recommendations. Although many occupations include fringe benefits of paid sick days, or even
time off with pay to keep medical appointments, other occupations have no such benefits. In the latter instance,
days taken off from work because of illness or for follow-up visits to the physician may result in decreased
income. Unfortunately, many people in these employment situations may also be part of a socioeconomic group
that can least afford to take days off without pay. In such cases, no matter how complete patient teaching is
about the necessity of staying home or of returning for a follow-up visit, the likelihood of adherence with such
recommendations is slight.

Awareness of these factors by health professionals may help them to modify the teaching plan to maximize
the patient’s ability to follow recommendations under the given circumstances. For instance, it may be sufficient
for the patient to call the health professional with a progress report rather than returning for an office visit. Or, if
the patient cannot remain at home for a week, the provision of rest periods during the working day may be
sufficient. If rest or follow-up visits are crucial, the health professional may refer the patient to a community

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agency where financial assistance for such expenses may be available. It is essential, in any case, that the
problem be identified and addressed if patient teaching is to be effective.

Economic consequences of illness may, on the other hand, in some cases cause a reverse reaction by the
patient. If patients receive financial benefits as long as they are ill, and especially if the opportunity for
satisfactory employment is slight, they may be less likely to follow recommendations that help them return to
health and optimal functioning if their benefits will be diminished or eliminated as a result.

Economic factors may also affect patients’ willingness to follow preventive health practices, especially if
patients do not view the benefits of the prescribed recommendations as being worth the cost. For example,
people with limited economic resources who have no perceived illness may choose not to follow their physician’s
recommendations to return for an annual physical. Women with limited financial resources may neglect
mammography because of the cost. Patients being treated for strep throat or a urinary tract infection may not
return for a follow-up visit because of the cost, even though its importance has been explained to them.
Awareness of patient’s financial concerns enables the health professional to problem solve with the patient to
reach alternatives. When patients’ concerns are identified and considered, the health professionals may also
weigh the benefit of making recommendations they know the patient will not be able to follow.

Reactions to illness are also dependent on the meaning the patient attributes to the condition. For instance, in
some cases, the patient may believe that the illness is a punishment for a transgression earlier in their life. If
they believe the illness is a punishment for their transgression, they may be less likely to follow
recommendations to aid in recovery or management of their condition if they believe recommendations interfere
with punishment that is “deserved.”

Such was the case of Mr. Anderson, who was diagnosed with non-Hodgkin’s lymphoma. After diagnosis he
refused any treatment saying to the nurse, “I knew it would catch up to me eventually. I cheated on my wife the
first year we were married, and I’ve been cheating on her ever since. She’s a good woman. I don’t deserve her.
This is now my comeuppance.” In other instances, patients may experience guilt because they perceive their
behaviors as contributing to their illness. This was true of Mr. Taylor who developed chronic obstructive
pulmonary disease after years of heavy smoking. He refused most patient teaching, and became increasingly
nonadherent with treatment recommendations, stating “I brought this all on myself. I should have given up
smoking years ago, just as my physician and family asked me to do. I’ve made my bed. Now I guess I’ll have to
lie in it.”

TEACHING PATIENTS HOW TO COPE WITH ILLNESS
Illness can alter an individual’s identity, distort thinking, and disrupt the way patients view themselves and the
world, creating a sense of vulnerability. Illness shatters the patient’s magical belief that they are immune from
illness, injury, or even death. Some patients may react with superstition, grasping at straws, searching for ways in
which they can again feel they have control. Patients may lose a sense of security and of cohesiveness. They
may become frustrated and angry at their sense of helplessness or loss; some become self-absorbed, others
more dependent. While some patients may draw on hidden resources of strength and courage, others become
more demanding, clinging, or regressed. Some patients may react with rebellion against medical advice. Life may
become a maze of inconveniences, hazards, and restrictions. With others, recommendations may be adapted
into their regular way of life.

One goal of patient teaching is to help patients to reorganize, make necessary changes, and maximize their
resources. This requires a nonjudgmental attitude on the part of the health professional, along with an effort to
understand patients and their reactions. If health professionals are unable to empathize with patients and their
reactions, such nonacceptance may well in itself push patients into nonadherence.

For example, Ms. Capanio, at age 20, was diagnosed with diabetes. Despite extensive patient teaching
sessions with the dietitian, she continued having difficulty following the prescribed diet. During teaching
sessions, the dietitian observed that Ms. Capanio showed little interest in the diet instructions. Rather than
criticizing Ms. Capanio for her lack of interest or for failure to follow the diet, the dietitian hypothesized that she
was having difficulty adjusting to the dietary restrictions, and that she may be having difficulty accepting the
condition in general. The dietitian demonstrated an understanding of Ms. Capanio’s feelings by taking time to
listen to her expound on the difficulties she was having with the recommendations and allowing her to vent
feelings. Such actions showed acceptance of, as well as interest in, Ms. Capanio as a whole. Such an
atmosphere is more conducive to working with patients to institute behavior change than one created by an
adversary relationship. The latter may result in rebelliousness or rejection by patients, limiting the chances to
achieve the level of adherence desired.

Illness often creates a sense of uncertainty and unpredictability. Patient teaching can help to restore a sense
of control, reducing the patient’s sense of powerlessness. By helping the patient understand manifestations of

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the condition and its treatment, and identifying issues the patient is facing, the patient and health professional
work together toward initiating strategies that facilitate adjustment. In order to best help patients cope, health
professionals need some understanding of various strategies and methods patients use to cope with the stress
they are experiencing as a result of their condition and their attempts to adapt to it.

UNDERSTANDING PATIENT COPING STRATEGIES AND METHODS OF ADAPTATION
Stress is a normal part of life even in healthy individuals, and anxiety is a normal reaction to stress. Stress cannot
be easily quantified and may be defined differently by each person. In order to cope with stress, individuals
mobilize a set of psychological strategies, which are used to decrease the impact of the stressful situation
(Billings & Moos, 1981; Krohne, 1993; Lazarus & Folkman, 1984). Each individual has his or her own unique way of
dealing with stress through coping strategies, which have been learned and developed over time. Coping is
complex and multifaceted (Livneh & Cook, 2005). Individuals use these coping strategies to manage, tolerate, or
reduce stress and to restore equilibrium. In illness, stress may be more pronounced and related to biological,
psychological, social, cultural, or environmental factors. A patient’s ability to cope is dependent on the
effectiveness of coping strategies, the patient’s perceptions of the impact the condition has on various areas of
his or her life, and the degree of threat the condition represents to the individual. Potential threats of illness as
perceived by the patient may involve those to life or well-being; to comfort; to independence, privacy, autonomy,
and control; to identity and self-concept; to future plans and goals; to social and family relationships; and to
economic well-being (Falvo, 2009).

When confronted with illness, patients usually revert to the predominant coping strategies that they have
used effectively to cope with stress in nonillness situations. There are times, however, that stress becomes so
great that old coping strategies are no longer effective, or old coping strategies are no longer appropriate to the
situation. In these instances, new coping strategies must be developed. Effective use of coping strategies
reduces anxiety, helps patients attain emotional equilibrium, and helps patients avoid incapacitation from fear,
anxiety, or other emotions that interfere with their progress toward goals. Although use of coping strategies can
be helpful, overuse can have the opposite effect, immobilizing the individual. Coping is effective and adaptive
when it helps individuals reduce stress and help reach their goals. It is ineffective and maladaptive when it
inhibits the individual from reaching goals, or contributes to negative health consequences.

How well individuals have coped with stress in the past will determine to some extent how they will cope with
the stress of illness. Many people take their health and body for granted, as well as their continued ability to
perform daily activities and social roles. When people are ill—whether the illness is acute or chronic, a result of
trauma, or a slow progressive disease—their lifestyle is interrupted, and varying degrees of stress are
experienced.

Coping can help patients adjust to their condition and follow recommendations; however, coping can also be
detrimental to positive patient teaching outcomes. The health professional’s awareness of patient coping
strategies can promote and foster those that contribute to positive outcomes and help patients develop new
strategies to replace those that are no longer effective in their current situation.

Denial
Denial is a coping strategy used to negate the reality of a situation. In some instances, denial can be useful as a
protective device to prevent the patient from experiencing overwhelming stress. For instance, in the event of a
sudden, catastrophic event that the individual finds devastating, denial of the seriousness of the event and its
implications can reduce anxiety, enabling the individual to adjust to the reality of their situation at their own pace.
Extended or overuse of denial can also have negative effects and become dangerous if it prevents the patient
from seeking medical care or following advice that is crucial to recovery or palliation of a condition.

An example of the negative effects of denial as a coping strategy can be illustrated by the case of Mr. Jacob,
who had consulted a physician because of what he considered indigestion. After examination, the physician
concluded that Mr. Jacob’s symptoms were the result of coronary artery disease. The physician recommended
cardiac catheterization and also recommended that Mr. Jacob schedule an appointment with the nurse for a
patient teaching session about heart disease as well as about the procedure. Mr. Jacob failed to make the
appointment for patient teaching and did not have the cardiac catheterization. He confided to his wife that the
physicians were just out to make money, and that he was not going to have any expensive tests just to prove he
had indigestion. Mr. Jacob had experienced such anxiety at the potential diagnosis and procedure that he
unconsciously implemented denial as a coping strategy. To have attended the teaching session or to have had
the procedure would have been admitting that the possibility of the diagnosis existed.

As illustrated above, denial can have an impact on patient teaching efforts as well as on adherence. When
confronted with patients who are using active denial as a coping strategy, forcing the patient to acknowledge

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facts only increases their stress and anxiety, and thus strengthens denial. Health professionals should not
actively engage in challenging the patient, but should rather assess the level of patient anxiety and seek other
means to help reduce anxiety, so that the patient is able to relinquish their false beliefs.

In other instances, patients may exhibit ambivalence about learning more about their condition. They may
adopt a “What you don’t know won’t hurt you” attitude, consequently resisting patient teaching. To force
information upon the patient is of little benefit. A more efficient approach at this point is to determine what
information is essential for the patient to have, proceeding to deliver it in bits and pieces, and monitoring patient
acceptance along the way.

At the other extreme, some patients cope with anxiety about their illness by wanting to know every detail of
their condition and its treatment. The use of this coping strategy can help reduce anxiety by reducing patients’
fear of the unknown and by helping patients feel as if they are in control of their condition. This type of reaction
can, quite naturally, be beneficial to patient teaching. Health professionals should not only provide initial
information to patients in this situation but also make sure that continuing information is provided about their
illness and progress.

Determining how patients are coping with their condition can help the health professional judge how much
and what type of information may be the most useful for the patient at that particular time. By remaining open,
supportive, and empathetic to patient feelings, the health professional will gain the opportunity to continue to
monitor and be available to the patient in the future. Gradual provision of information when the patient is ready to
receive it can reduce patient anxiety, and create increased receptiveness to additional information and
incorporation of the information into their life.

Compensatory Strategies
Illness can cause alteration in an individual’s activities or areas of function. When this occurs, individuals may
mobilize strategies to compensate for real or imagined limitations experienced due to illness by becoming
stronger or more proficient in another area. For example, Ms. Lawrence had enjoyed dancing as a creative outlet
of self-expression; however, after developing emphysema, she was unable to maintain a level of physical activity
that would enable her to participate in dancing. Instead, she developed writing skills as a means of self-
expression, thus increasing self-satisfaction without requiring excessive physical strain.

Although use of compensation as a way of coping can be highly constructive, it may also be destructive and
detrimental. For instance, Ms. Kapur felt unattractive after having a radical mastectomy. She compensated for
her perceived unattractiveness by becoming promiscuous. Another example of the detrimental use of
compensation is the case of Mr. Atkins, a cardiac patient who was no longer permitted to smoke but
compensated by eating excessively.

Providing patients with information alone about their condition and treatment in each of these instances is
insufficient if patient teaching is to be effective. Recognition of patients’ reactions can, however, be the first step
in helping them learn to cope with their feelings about their condition and treatment, and can subsequently
increase the potential effectiveness of future patient teaching. Through patient teaching, health professionals
can help patients learn ways to maximize existing skills or to develop new skills to replace those lost because of
their condition. In the instance of Ms. Lawrence described earlier, the health professional helped her explore
other activities, which helped her to find another creative outlet for the one she had lost.

Taking time to understand the patient’s reactions helps the health professional establish an alliance and
atmosphere of collaboration in which issues that may serve as barriers to reaching treatment goals, or may be
detrimental to the patient’s health status can be addressed. In the cases of Ms. Kapur and Mr. Atkins described
above, regardless of the health professional’s view, it is the patient’s perceptions, values, and judgments that are
the issue. Whether or not the health professional believes that Ms. Kapur is unattractive or that overeating is as
detrimental as smoking is of little consequence. It is the patient’s perceptions and beliefs that determine
behavior. Consequently, awareness of these factors can help the health professional develop strategies and
interventions to address them.

Benign Forgetfulness
Some patients may cope with stress experienced as a result of their condition by subconsciously expelling
disturbing facts or situations from their minds. Benign forgetfulness can be beneficial in helping patients reduce
anxiety, as was the case of Mr. Goldberg, a patient who had experienced serious burns and was treated in the
regional burn center. After leaving the hospital, and in preparation for future reconstructive surgery, Mr. Goldberg
forgot the severity of pain he had experienced during dressing changes, and instead remembered the kindness
of the hospital staff and the positive aspects of rehabilitation. In this instance, forgetting the unpleasant part of

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his experience contributed to his willingness and ability to continue to progress with rehabilitation and treatment
recommendations.

As with most coping strategies, benign forgetfulness can be positive and help patients cope with stress and
adjustment to their condition, but in some instances it can also interfere with adjustment and subsequently with
adherence. For example, Mr. George, who consistently experienced periodic chest pain and shortness of breath
“forgot” about his symptoms when he went to see his physician and consequently failed to report them. Ms.
Carlon consistently “forgot” her dental appointment for a root canal.

Benign forgetfulness can take considerable energy, and while it can be helpful, it can also be potentially
harmful. Recognition of the patient’s excessive use of this coping style can help the health professional either
reinforce its use when it is helpful, or mobilize a process to enhance more realistic confrontation of the problems
or issues at hand when its use is detrimental. When benign forgetfulness is used in a productive manner, such
as in the case of Mr. Goldberg, facilitation of this coping style can help the patient achieve more positive health
outcomes. If the health professional recognizes that a patient appears to be a “chronic forgetter,” and that such
behaviors are detrimental to his or her care, intervention may be necessary. Rather than approaching the patient
in an accusatory way, the health professional may spend some extra time talking with the patient about his or her
feelings concerning the condition and treatment. Through a relationship of trust and mutual respect, the health
professional will be better able to help the patient identify and disclose feelings, making a problem-solving
approach more likely.

Avoidance
Some people use avoidance as a strategy to cope with their illness. Avoidance involves removing oneself
emotionally or physically from a situation that is anxiety producing. If the situation is potentially dangerous, then
avoidance or withdrawal from the situation is, of course, constructive. For example, Ms. Little had been in
recovery from alcohol dependence for 2 years. She received an invitation to attend a reunion of her “drinking
buddies” who she knew still abused alcohol, and many of whom were still alcohol dependent. She knew that
most of them continued to be in denial of their substance abuse and dependence and that they would place
extreme pressure on her to join them in drinking. Although she had faith in her ability to resist the temptation to
drink again in most situations, she feared her ability to resist in the situation with her former friends.
Consequently, she declined their invitation and avoided the activity.

A less constructive use of avoidance as a method of coping may occur in cases in which individuals refuse
to learn needed behaviors because of fear of failure. Such was the case of Mr. Carter, who had recently
experienced an above-the-elbow amputation as the result of a farming accident. Although the prosthetist
continued to attempt to work with Mr. Carter, and show him how the prosthetic device could be used to increase
function, Mr. Carter refused to learn to use the prosthesis, fearing that he would appear silly or would be unable to
perform the activities adequately.

Avoidance may be used emotionally as well as physically. Emotional avoidance may also have positive and
negative aspects. In some instances, emotional avoidance may be a necessary part of helping patients cope
with stresses experienced because of their illness. For instance, Ms. Angeles was diagnosed as having a
meningioma of the temporal lobe of her brain. Although the physicians explained that the surgery posed some
risk and loss of function as a result of removal of the meningioma, Ms. Angeles remained calm, avoiding
thoughts of any potential negative effects, and focusing only on positive outcomes. Emotional avoidance may,
however, interfere with patients’ health care and treatment, as well as their receptiveness to patient teaching. Mr.
Markel underwent surgery for removal of his pancreas after being diagnosed with pancreatic cancer. After
surgery, when the nurse attempted postoperative teaching regarding insulin administration, as well as teaching
him about the enzymes he would need to take daily, she noted that he was inattentive and often changed the
subject. The nurse suspected that the Mr. Merkel felt overwhelmed by the diagnosis as well as the treatment,
and was avoiding learning the information as a way of coping with his anxiety. Through this realization, the health
professional was better able to employ strategies to help Mr. Merkel cope with his anxiety, thus increasing the
probability that the teaching would be effective.

Role Modeling
Role modeling as a coping strategy consists of internalization of attributes of another into an individual’s own
behavior or attitudes. Role modeling can, of course, have positive and negative consequences depending on the
behaviors or attitudes the patient chooses to model. When the patient models behaviors and attributes of others
who are managing their illness and treatment successfully, use of role modeling is positive. Health professionals
may foster this type of role modeling for patients to help them adjust to their illness by doing such things as
asking a patient with an ileostomy who is now leading an active life to visit a hospitalized patient with a new

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ileostomy. Role modeling may have a negative effect, however, if patients are exposed to others with similar
conditions who have not adjusted well to their illness, or are managing their illness in a maladaptive way, such as
a patient on dialysis who is nonadherent to dietary recommendations between dialysis treatments. In these
instances, the patient may incorporate the negative attitudes or behaviors expressed by these individuals. In this
case, role modeling would be detrimental to the adjustment of the patient. In patient teaching, knowledge of this
method of coping can be facilitated by providing role models that help the patient achieve positive health
outcomes. Knowledge of role modeling as a strategy patients use for coping can also help the health
professional identify those instances in which negative effects emerge.

Regression
In regression, individuals revert to immature behavior that was part of their behavioral repertoire at an earlier
stage of development. It is used to some degree by most persons when ill, whether the illness is acute or
chronic, major or minor. Most people, even when only ill with the flu, exhibit more childlike behaviors, such as a
short temper, excessive emotionality, or dependency, than they may normally exhibit in their adult roles.
Regression, especially in the early phases of illness, may even be necessary to eventual recovery. For instance,
patients with a new myocardial infarction, as part of treatment, may need to regress to a more dependent …

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their illness that can have a negative impact on their ability to function as well as to follow recommendations.
Awareness of a patient’s use of regression as a coping strategy can help the health professional adapt teaching
accordingly by anticipating potential problems with patient receptivity to information or problems that may
interfere with the patient following recommendations.

Blaming Others
When an individual’s thoughts, impulses, or ideas produce stress or are unacceptable to the individual, he or she
may cope by attributing his or her thoughts or feelings to others, or blaming individuals for his or her condition. For
example, Mr. Mason sustained an injury to his spinal cord resulting in paraplegia. The injury occurred in a car
accident in which Mr. Mason was driving while intoxicated. His wife was in the car, but had not been drinking. She
was uninjured. Mr. Mason exhibited hostile behavior toward his wife every time she came to visit, telling her that
had she had distracted him in the car and consequently blamed her for the accident and his injury.

In another instance, Ms. Andrews sustained an injury that caused her to limp and use a cane. She had
negative feelings and views about people with a disability prior to experiencing her injury. Instead of recognizing
her own feelings about people with disability, however, she ascribed negative feelings to others, believing that
everyone looked down on her now that she appeared disabled, regardless of whether or not negative behaviors
were actually exhibited by others. As a result, during a teaching session in which the physical therapist was
monitoring ambulation with a cane, Ms. Andrews exploded by saying, “You don’t think people with a limp like
mine have much worth in the world, do you?” If the physical therapist had been unaware of the reason behind Ms.
Andrews’ statement, he could have been bewildered or defensive. However, because he recognized the reaction
as a coping strategy, he was able to explore Ms. Andrews’ feelings and help her learn how to cope more
effectively.

If the health professional is aware of the patient’s anxiety and feelings, patient teaching can be better
adapted to first cope with the patient’s feelings, then proceed to teach the patient about their condition or
treatment. For example, in the preceding situation, rather than responding to Ms. Andrews’ statement with a
comment like, “How can you possibly accuse me of such a thing when I’ve spent so much time trying to help
you?” the physical therapist may offer a response such as, “No, I don’t feel that way, but I’m wondering why you
asked. Tell me a little more about your question.”

By encouraging patients to talk about their feelings, health professionals demonstrate acceptance as well as
gain insight into patients’ feelings and behavior. To pursue patient teaching without first gaining more information
about patients’ statements sets a precedent for less-than-desirable outcomes. Again, although adherence
cannot be guaranteed by helping patients cope with their feelings, the more accepting patients are of their own
conditions, and the more they feel the health professional is accepting of them and willing to listen to their
concerns, the greater the possibility is that patient teaching will be effective.

Patients may also blame their own nonadherence on others, stating that family members are uncooperative
or unsupportive of their treatment. Because this may be true in some instances, health professionals should
assess the validity of patients’ statements before drawing conclusions. If it is found that, in fact, the patient’s
family appears supportive and actively encourages the patient to follow recommendations, then the use of
blaming as method of coping by the patient may be suspected. The health professional can then incorporate
interventions into patient teaching by which the patient is gradually helped to cope with anxiety and to accept
responsibility for his or her own actions.

Self-Blame
Anger may be a reaction experienced by patients when they develop a chronic illness or disability. Rather than
expressing anger toward others, however, individuals may cope with their feelings of anger by turning them
inward and blaming themselves. For example, Mrs. Sherman developed significant hearing loss after
experiencing a blow to the head when she fell during a rock climbing trip with her husband, an activity she never
enjoyed and only reluctantly participated in. During her aural rehabilitation, her husband became very impatient
with her hearing loss and was relatively unsupportive of her attempts to compensate for her hearing loss with
alternative means of communication. Instead of becoming angry with her husband, Mrs. Sherman frequently
made statements such as, “I have no patience. I’m so selfish. I expect entirely too much from my husband. It
must be so difficult for him to have to live with me now. If I only had been paying more attention, I never would
have fallen. I brought all of this on myself, and now he has to suffer because of my stupidity.”

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Health professionals who are alert to cues such as those demonstrated by Mrs. Sherman can help patients
recognize and express those feelings, thereby offering the opportunity to discuss problems that may interfere
with patient teaching or their following recommendations.

Rationalization
Rationalization consists of providing false reasons, which are socially acceptable to explain what is often
considered unacceptable behavior to offset negative feelings or consequences. This method of coping enables
people to invent excuses for not doing things they know they should have done, as well as helps to soften
disappointment if desired goals were not met. Rationalization can affect patient teaching as well as adherence.
For example, when Mr. Giovanni, who has diabetes, went off his diet, he rationalized, “I’ve been following my diet
very well, so I deserve a little break. It won’t hurt to cheat every now and then.”

Appointments for various diagnostic procedures may be missed for reasons such as, “They probably wouldn’t
find anything wrong, anyway, so it’s better that I gave up my space for the test to someone who really needs it,” or,
“There’s no reason to spend the extra money for a mammogram, since I have no family history of cancer. I’ll use
the money I would have spent had I kept the appointment to support the local food bank.”

Rationalization as a method of coping can also play a positive role in adjustment to illness. For example, when
a chronic illness limits the amount or type of activities in which a patient may participate, statements such as,
“I’ve really had more time to get to know my family since I’ve been ill and haven’t been able to run around doing all
the things I used to do. All the other things I used to do were pretty meaningless, anyway,” or a statement such
as, “I never really enjoyed running in competition anyway. Just watching as a bystander is much more pleasant”
may illustrate examples of rationalization as a method of coping that can be reinforced.

Reinforcing the positive use of rationalization can enhance effectiveness of patient teaching. In instances in
which rationalization produces negative outcomes, health professionals might direct teaching efforts toward
helping patients discuss their feelings about their condition, gradually helping them accept a more realistic view
of their condition and treatment.

Hiding Feelings
At times, patients react to their illness or to those around them by behaving in a way that is opposite to their
actual feelings or thoughts. For instance, the patient using this method of coping may appear to be excessively
cheerful and unconcerned about the illness and its implications while actually feeling very frightened and sad. In
other cases, patients may be especially charitable to family members or individuals around them when they are
really feeling hostile and resentful. Hiding feelings as a coping strategy can be of value in adjusting to illness if it
helps the patient maintain behavior that is socially acceptable. It is detrimental to the extreme that it is self-
deceptive and prevents the patient from recognizing and dealing with actual feelings that, if hidden long enough,
may result in additional stress.

Through accurate assessment and understanding of patient behavior, health professionals can individualize
patient teaching so that it is better suited to the individual needs and reactions. Whether this involves referral to
another professional or merely encouraging patients to verbalize their feelings, by recognizing the impact of
patients’ reactions to their condition, health professionals are in a better position to alter the approach during
patient teaching, which in turn makes patient teaching more effective by increasing the chances of adherence.

Redirecting Emotions
Most people, at one time or another, as a method of coping, redirect emotion from the person or situation
originally provoking the emotion to an individual or object that seems less threatening. Take the example of Mrs.
Garcia. Mrs. Garcia came into the hospital for a hysterectomy because of fibroid tumors. During the routine
preoperative exam, the physician also found a lump in her right breast. Upon biopsy, the lump was found to be
malignant and a mastectomy was performed. Mrs. Garcia was angry with the physician for giving her an
unfavorable diagnosis, and one she had not expected. Rather than venting anger at the physician, Mrs. Garcia
became very disagreeable and hostile to the nurse who attempted to teach her about self-care at home. Rather
than directing her emotion to the physician, who was actually the source of her anger, Mrs. Garcia expressed
anger toward the nurse, a person she felt was less intimidating and less threatening.

Although redirecting emotions can be valuable in the sense that it allows the individual to release strong
emotions without threat of retaliation from individuals who may be perceived to be more powerful, those people
at whom anger is directed may become alienated. Because she recognized Mrs. Garcia’s behavior as a reaction
to stress, rather than becoming angry in return, the nurse attempted to encourage Mrs. Garcia to express her

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feelings. She discontinued further teaching until Mrs. Garcia was more receptive to the information she planned
to give her.

Excess Activity
Some people react to illness by engaging in activities that distract them from thinking about their condition, or by
thinking about things other than the issue at hand. Although this coping style can be positive if used in a
constructive way (dwelling on symptoms or implications of disease to the point of inactivity is not therapeutic),
its overuse prevents people from dealing realistically with their feelings about their condition and the limitations
that may be imposed by it. Such was the case of Mr. Hester, recently diagnosed with diabetes. Mr. Hester’s
insulin was to be regulated on an outpatient basis. He was also to return as an outpatient for regular patient
teaching sessions. At the outpatient visits, Mr. Hester always seemed extremely pressed for time. He frequently
seemed preoccupied with other commitments during the sessions. Both the physician and the nurse noted that
Mr. Hester appeared to be overextending himself. When Mr. Hester had an appointment for patient teaching, he
often called saying that he had a pressing commitment that kept him from attending. If he arrived, he seemed
preoccupied throughout the visit, saying that it would have to be short because he had numerous other
appointments to keep. He failed to read most of the materials about diabetes given to him, saying he had been
too busy even to glance through them.

The physician and the nurse questioned Mr. Hester about how he might be able to arrange some of his other
activities to allow more time for his scheduled appointments. He replied simply that there was no other way to
arrange the schedule of an extremely busy man. Aware of the possibility that Mr. Hester might be anxious about
his condition and using excess activity to escape facing his feelings, the physician and the nurse used each
contact with Mr. Hester to allow him to express some of these concerns until gradually he became aware of his
behavior as a method he had been using to avoid dealing with his diabetes.

Diverting Feelings
One of the most positive and constructive of all methods of coping can be the diversion of unacceptable feelings
or ideas into socially acceptable behaviors. Patients with a chronic illness or traumatic injury, for instance, may
have particularly strong feelings of anger or hostility about their diagnosis or the circumstances surrounding their
injury. If the energy of their emotions can be diverted into positive activity, however, the result can be quite
beneficial. An example of such a diversion may be the case of Mr. Meyer with Parkinson’s disease. He has strong
feelings about having the condition but directed his strong emotion into a positive activity. He worked relentlessly
to establish a local Parkinson’s disease support groups for patients and their families, participated regularly in
fund-raising activities for research on Parkinson’s disease, and often appeared as a guest speaker at public and
civic events about Parkinson’s disease.

Health professionals who notice this method of coping during patient teaching can facilitate positive
outcomes through its use. Patients may be encouraged to participate in teaching activities directed to other
patients with their condition or they may be asked to serve as role models for those with similar conditions,
discussing common areas of concern and offering suggestions and support.

As with all other methods of coping, indiscriminate use or misuse of diversion can be very negative. Ms.
Lankford, after experiencing a spinal cord injury resulting in paraplegia, began going to casinos to gamble; soon,
her gambling turned to excess and she accumulated massive debts. Before health professionals facilitate the
use of diversion by patients as a coping method, they should carefully assess the patient’s attitudes and
knowledge base to be sure that diversion is being used in a positive way and that the patient actually is serving
as the positive role model, and is not detrimental to the patient’s well-being.

HELPING PATIENTS COPE
Reactions of patients to disease, illness, or disability are variable. Methods of coping discussed in this chapter
are common behaviors learned and used by all individuals to some degree to adjust and adapt to the stress of
daily life. Such methods of coping, because they are part of everyday life, are normal and desirable. In illness,
individuals may use the same methods for coping with stress that they used in their healthy state, or coping
patterns may become more pronounced. The danger emerges when use of coping methods is excessive and
prevents the individual from adapting or reaching their potential, or when their use is detrimental to their health or
well-being.

In the case of an individual with illness, overuse of coping methods can interfere with medical care or
treatment. It is not within the role of most health professionals conducting patient teaching to attempt to
drastically alter patients’ methods of coping. In order to facilitate patient teaching effectiveness, however, it is

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important for health professionals to be aware of different coping methods so they are better able to understand
the behavior of individual patients, anticipate potential barriers to effective patient teaching, and work toward
solutions to overcome barriers or problems. The better able health professionals are to view the situation from
the patient’s perspective, the less likely they are to avoid or dismiss the challenging patient. By understanding
patients’ perceptions of health and illness, health professionals are better able to empathize and be more
sensitive to the patients’ needs, thus conducting patient teaching accordingly. By understanding patients’ coping
methods, health professionals are better able to encourage patients to express their feelings and to encourage
and motivate them to follow recommendations.

Allowing patients to express their fears and feelings in a nonjudgmental, empathetic atmosphere, along with
developing a sensitive teaching plan based on patients’ needs, can reduce patient anxiety, help them to adjust to
their condition, and maximize the probability that they will adhere with recommendations.

Patients’ anxieties or other concerns can interfere with the effectiveness of patient teaching. Timing of
patient teaching is important, especially to the patient’s readiness to learn. Early after diagnosis of serious illness
or injury, for example, patients may focus only on the restrictions imposed on them by their illness. They may see
few positive aspects in information offered during patient teaching. Although at this stage, patient teaching may
not have an immediate impact, it is important for the health professional to meet with the patient to begin to
establish a relationship. This early intervention should be directed toward laying a foundation for effective
teaching later. Initially, patients may have little awareness of the implications of their condition and their
reactions to their condition may be minimal. Building rapport with the patient during the early stages of the
patient’s illness helps to establish a relationship that will be better able to withstand possible later reactions of
anger, frustration, or depression that patients may exhibit.

As patients eventually begin to recognize the impact of their condition on their lifestyle or on longevity, or
when they begin to realize the extent of loss or limitation, they become anxious—not necessarily in proportion to
the seriousness of the illness. During this phase, anxiety may interfere with learning. Instead of bombarding
patients with extensive information at this time, it may be far more productive to effective teaching outcomes to
assist them to express their fears, questions, and concerns. Acceptance of patient fears and concerns rather
than offering superficial reassurance helps to build trust and rapport, which can later facilitate patient teaching.
Such phrases as, “Oh, I’m sure everything will be fine,” or, “Lots of other people have your condition,” are likely to
be rejected by patients and can establish barriers that interfere with further teaching effectiveness.

To help patients cope with their anxiety, any number of combinations of the coping methods discussed in this
chapter may be used. If methods of coping are severely impaired so that they are interfering with medical care or
the individual’s ability to function, referral to other health professionals for in-depth counseling may be indicated.
Such suggestions may, however, be met with resistance if offered by a health professional who has not
established a trusting relationship with the patient. Blind persistence at patient teaching at this stage is a waste
of time for both health professional and patient, and may also interfere with the possibility of patient teaching
effectiveness later. It may be more important during this time for the health professional to gradually provide
realistic information in a supportive manner, giving the information with sensitivity, but also not reinforcing the
patient’s false beliefs.

Patients who accept their condition and subsequent limitations may become depressed as they
acknowledge perceived losses. The health professional conducting patient teaching should not equate this
reaction with a lack of motivation or with an inadequate teaching plan or strategy. It is more productive at this
point for the health professional to accept the patient’s right to grieve, at the same time establishing short-term
teaching goals that continue to move the patient forward. To discontinue efforts toward patient teaching totally or
to provide only sympathy at this point may encourage the patient to assume maladaptive patterns of behavior
that are not consistent with independence and positive health outcomes.

By accepting, acknowledging, and helping patients work through their initial reaction to illness, health
professionals also help people adjust to new limitations or special treatment recommendations that may be
associated with the illness. Effective patient teaching is dependent on patients reaching this point.

Although there is no way to accurately identify individual methods of coping, health professionals should be
aware of their existence and explore possibilities. Rather than using a method of coping, the patient may be
reacting to other environmental factors or to a differing belief system. Only through continued observation,
assessment, and information gathering, can health professionals gain additional insight into patients’ behavior.
Behaviors of health professionals are important in facilitating this process. Facilitative behaviors for the health
professional are illustrated in Table 4-1.
 

Table 4-1 Facilitative Behaviors

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1. Recognize that coping styles are defenses patients use to protect themselves from threat, either
real or imagined.

2. Recognize that patients’ reactions to their conditions and recommendations will be determined by a
combination of personal characteristics, learning history, and current circumstances.

3. Avoid stereotyped approaches to patients or to the content of information presented. Even patients
with the same conditions do not adapt and react in the same way.

4. Set aside assumptions, and perform a careful assessment of the present beliefs, reactions, and
circumstances of each patient.

5. Recognize that timing of the teaching intervention is important to the patient’s readiness to learn and
to work toward established goals. If a good relationship has not previously been established,
suggesting that the patient change may lead to rejection of other education efforts.

6. Lay the foundation for effective teaching later with empathetic understanding.

7. Acknowledge and accept patients’ fears, frustrations, and other reactions in an understanding way.

8. Give sensitive support that recognizes the stress patients feel.

9. In instances of denial or other coping styles that appear to be having a detrimental effect, gently and
gradually confront the patient with reality.

10. Avoid agreeing with patients’ statements that do not appear to be an accurate representation of fact;
do not reinforce patients’ negative beliefs.

11. If the coping style is not interfering with the patient’s condition or treatment, leave it alone.

ENHANCING PATIENT ADHERENCE
Many variables impact an individual’s ability and readiness to follow healthcare recommendations and the impact
of nonadherence varies in its magnitude of seriousness. Some acts of nonadherence may be trivial, but others
can have significant impact on patients’ health, well-being, and overall quality of life. The purpose of effective
patient teaching is to help patients understand the purpose and importance of recommendations and to facilitate
their ability to make informed choices. In order to be effective, patient teaching must be patient-centered, and
based on individual patients needs, circumstances, and goals. Effective patient teaching is conducted in a
nonjudgmental atmosphere of respect and support. Effective patient teaching facilitates patient adherence.

Facilitation of patient adherence, in this sense, should not be confused with coercion. Rather, increasing a
patient’s ability and willingness to follow recommendations should be directed to understanding the patient’s
supports and barriers to following recommendations as well as understanding and accepting patient goals. By
listening to patient concerns, and understanding the patient’s unique perspective and experience, health
professionals begin to establish an atmosphere of collaboration and partnership. Health professionals
conducting patient teaching should present themselves to patients as consultants rather than authoritarians,
never criticizing patients’ efforts or criticizing their failure to follow recommendations as expected. Patients may
have their own reasons for not following recommendations. By providing empathy and support, as well as
feedback and guidance, health professionals help patients to consider recommended changes and enhance
their ability to follow them.

Understanding patient resistance, lack of motivation, and nonadherence can help health professionals
become more effective in helping patients achieve health-related goals. One model that may provide insight into
more effective ways of providing patients with the assistance needed to help them achieve their goals is the
Stages of Change model (Miller, Sovereign, & Drege, 1988; Prochaska, DiClemente, & Norcross, 1992; Rollinick,
Kinnersley, & Stott, 1993; Kushner, Levinson, & Miller, 1998), as discussed in Chapter 3. The model proposes that
there are predictable stages of change and by understanding which stage of change the patient is currently
experiencing, interventions appropriate to that stage can be instituted to motivate the individual to change. Even
when change has been accomplished, change must be maintained. Patient teaching directed toward offering
continued support, encouragement, and reinforcement can help patients maintain the changes they have made.
Continued feedback about patient progress in maintaining their behavior is, in itself, reinforcing.

Effective patient teaching demonstrates respect for patients, their views, and their values. Effective patient
teaching focuses on helping patients make informed decisions based on individual needs and circumstances.
Health professionals should engage in ongoing examination of patients’ feelings and experiences related to their
illness and the recommendations. Listening to patients’, and offering them support can help to empower them so

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that they are active and engaged in the patient teaching process and are participants in reaching positive health
outcomes in accordance with their goals.

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Strategies in coping with aversiveness (pp. 19–50). Seattle, WA: Hogrefe & Hububer.
Kushner, P. R., Levinson, W., Miller, W. R. (1998). Motivational interviewing: What, when and why. Patient Care, 32(14), 55–56, 58, 64, 66, 69–72.
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CHAPTER 5

Patient Teaching Through the Lifespan: A
Developmental Perspective

LIFESPAN DEVELOPMENT
Knowledge of lifespan development is integral to effective patient teaching. Because the focus of attention in
patient-centered teaching is the patient, rather than the disease, knowledge of lifespan development is
fundamental for patient teaching to be effective. In order to fully understand the nature of issues, reactions, or
concerns patients bring to the patient teaching interaction, their situation must be considered in the context of
their stage of life. Knowledge of behavioral changes from conception to old age enables the health professional
to view patient issues from a developmental perspective. This allows patient teaching to be altered in
accordance with the patient’s developmental stage and the specific issues that may be associated with their
present point of development. Knowledge of lifespan development enables health professionals to use
strategies appropriate to the individual, rather than conducting all patient teaching the same way, regardless of
the patient’s age or life stage.

Each stage of life has its own particular stressors or issues apart from those experienced because of illness.
When people become ill, they experience additional stress. A patient’s reaction to illness and the type of stress
experienced may vary according to his or her developmental stage. The proper approach to patients differs at
particular phases of development. For instance, children obviously differ from adults—not only physiologically,
but in their reactions to illness. Just as treatment of illness differs in accordance with the patient’s age, patient
reactions and information needs and, consequently, the approach to patient teaching also differs at various
developmental phases. Because patient reaction to illness differs at various life stages, the approach to patient
teaching cannot be the same for patients who are at different stages of development, even though their
conditions may be similar. Teaching a child with cancer is certainly different from teaching an adult with cancer.
In most instances, language ability differs as well as the ability to understand concepts surrounding the
condition and its treatment. The person who has a myocardial infarction at age 40 will require a different
teaching approach than a patient who has a myocardial infarction at age 80. Lifestyle, responsibilities, and
attitudes are different in middle age than at older age. These contrasts affect not only patients’ reactions to their
condition but also their reactions to and motivation for carrying out recommendations.

The approach to teaching patients about prevention or providing them with information about potential
problems they may encounter also varies with age. Prevention teaching for a toddler, for instance, may involve
talking with the parents about child safety, whereas prevention teaching for adults may range from awareness of
health risk factors to stress reduction. An understanding of lifespan development helps health professionals to
recognize specific patient needs at various life stages, enabling them to give support in accord with particular
needs. Using a developmental approach to patient teaching can help health professionals understand and
anticipate patients’ reactions to illness, alter the approach to patient teaching in accordance with individual
needs, and identify patient teaching needs related to a particular life phase, all while teaching about a specific
disease entity.

Because all aspects of development are related, each life stage must be understood within the context of the
patient’s past experience and system of social support. Lifespan development is a continuing process without
clear lines of demarcation between life stages. For purposes of discussion in this chapter, life stages will be
delimited by category; however, phases of development for each individual, of course, are not separated nearly
so clearly.

MODELS OF LIFESPAN DEVELOPMENT

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There are a number of models of human development over the lifespan based on different theories and beliefs
of researchers who have studied systematic age-related changes in behavior or functioning over time. For the
most part, theories fall into three broad categories of models (Broderick & Blewitt, 2006):

1.   Stage models in which individuals are viewed as sharing some common behavioral characteristics during
different stages of life, which change as the individual moves through different life stages.

2.   Incremental models in which behavioral changes occur as a gradual, step-by-step process throughout the
lifespan.

3.      Multidimensional models in which behavioral changes are the result of reciprocal interactions between
internal characteristics of the individual and external characteristics of his or her environment.

Although no one theory or model of lifespan development has been accepted as the defining theory of
behavioral change over a lifetime, most theories characterize development as incremental; not a stepwise
progression, but rather a progression that continues from birth to death (Broderick & Blewitt, 2006). A lifespan
approach to development emphasizes potential for change throughout an individual’s life.

As individuals progress through life, development and change are not isolated from the influence of family,
social network, and culture. Individual environments include material objects, expectations regarding gender-or
age-related behavior, social structures, and behavior-guiding beliefs. Consequently, a lifespan development
approach to patient teaching must also consider developmental issues in the context of the individual’s social,
cultural, and physical environment.

Although there are many ways of viewing development, depending on the particular theoretical approach,
there are some commonalities on which most individuals studying development agree (Poole, Warren, & Nunez,
2007). One such commonality is the belief that development is gradual and incremental. A second commonality
is the idea that influences help to shape future behavior, with current functioning built on previous functioning. A
third commonality is that environmental influence on behavior may vary with time and context. For instance,
although environmental influences shaped the individual’s development at one point in his or her life, these
influences may be altered when the individual finds himself or herself in a different situation at a different life
stage.

PATIENT TEACHING WITH PARENTS AND CHILDREN
Teaching the Prenatal Patient
During the embryonic period, the individual is vulnerable to many hazards that influence development and health
potential, not only in utero, but also over a lifetime. Because growth and development of the fetus are so
dependent on the mother’s health and well-being, the prenatal period is an extremely crucial time. Although health
professionals obviously cannot deal with the fetus directly, effective teaching of the prenatal patient holds
paramount importance for the well-being of the fetus. Consequently, in order to be effective, patient teaching
during the prenatal period must consider not only the information that is critical to relay at this time, but also the
mother’s reaction to pregnancy. Her reaction may influence both her receptiveness to information and her ability
or willingness to follow given recommendations.

Pregnancy, even if planned and wanted, can be stressful. A variety of physical and emotional changes are
part of pregnancy. In addition, parents gain awareness of the considerable change in lifestyle and increased
responsibility that will likely result after birth of the child. Health professionals should be aware of potential
stressors associated with pregnancy as well as factors in patients’ individual life circumstances that may be
sources of support or that could cause additional stress. In this way, patient teaching can be adjusted in
accordance with patients’ specific needs.

Most parents have some ambivalence toward pregnancy and parenthood during the prenatal period, no matter
how much the pregnancy is desired, especially if it is a first pregnancy. Having total responsibility for another
human being may seem like an awesome task. The realization that parenthood means giving up certain
freedoms and fantasies may also cause expectant parents to reflect on their own past, present, and future goals
and aspirations. Although such ambivalence is natural, normal, and usually resolved, not all expectant parents
recognize it as a normal phenomenon. Consequently, such feelings may cause them considerable guilt.
Awareness of the potential for patient anxiety or guilt enables the health professional to promote discussion that
encourages patients to share their feelings. Health professionals can relieve stress by helping parents express
their feelings about the pregnancy and by offering reassurance, guidance, and support. Helping expectant
parents prepare for their role as parents can also help reduce stress and help new parents develop confidence in
their ability to assume their new role. During patient teaching, in addition to preparing them for the physical care
of their infant, encouraging parents to discuss their feelings, and offering reassurance and practical advice, not

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only helps them develop confidence in their ability as parents, but it also creates an open atmosphere in which
they feel comfortable addressing other feelings and concerns should they arise.

Stress may also be generated from the unknowns associated with pregnancy. Expectant parents vary in their
sophistication and knowledge about pregnancy, labor, and delivery. Health professionals can do much to alleviate
stress by teaching prospective parents about the emotional and physical changes to be expected during
pregnancy and about what to expect during labor, delivery, and the postpartum period.

It should not be assumed that a patient who has had multiple pregnancies has little need for patient teaching
or that stressors are not associated with her pregnancy. Individual responses to each pregnancy, as well as life
circumstances, should always be considered and addressed. If there are other children in the family, patient
teaching may also involve teaching parents how to talk with their children about pregnancy and birth, as well as
helping the children prepare for the addition of a new family member.

Although health professionals may have more contact with the prenatal patient herself, the impact of other
people in her life should not be underestimated. Including the expectant father in patient teaching promotes a
feeling of inclusion for him in the prenatal and birthing process. It can also do much to reduce stress between
the couple if there is a common understanding of changes to be experienced and what to expect. Not all prenatal
patients have a partner supporting them through pregnancy. In such instances, health professionals must be
aware of the additional stress this may cause and its impact on the patient’s health behavior, as well as other
potential sources of social support that may help the patient in carrying out the recommendations made in
patient teaching.

Many parenting behaviors are learned from family members, friends, or other social contacts outside of the
healthcare system. These individuals provide information as well as moral support and may even share care of
the infant. An awareness of the patient’s social network and their involvement in the pregnancy and future care
of the infant helps the health professional identify and address any issues that may arise from involvement of
family or friends. Whereas strong social networks can increase parents’ satisfaction with parenting and help the
parents gain confidence in their ability to care for their infant, not all social interactions are welcomed by the
patient, and can be a source of stress. By identifying patient feelings about the degree and quality of social
support they experience, the health professional is able to provide guidance and support as needed.

Just as it is important for the health professional to have an awareness of the patient’s social support, it is
equally important to be aware of lack of social support. Decreased access to supportive and competent social
networks have been found to predispose to patient sense of isolation, lack of parenting skill, and the potential for
abuse (Osofsky & Thompson, 2000). Knowledge of a patient’s level of social support can help health
professionals anticipate potential problems, offer support and guidance, and incorporate supplemental
information about parenting skills in patient teaching interventions. It also allows the health professional to direct
the patient to appropriate referral sources that may also be a source of support.

The approach to prenatal patients and significant people in their lives by the healthcare professional should
be open-minded and have no preconceptions. Health professionals should be aware of parental attitudes about
pregnancy and be alert to potential adjustment problems. When developing a patient teaching plan, health
professionals should also be aware of a patient’s current life situation, knowledge level, misinformation, and any
other barriers that may affect the patient’s receptiveness to information and ability or willingness to carry out
recommendations.

Common informational content areas for most patients in this life phase are the normal emotional and
physical changes associated with pregnancy, such as sexual activity during pregnancy, preparation for the
newborn, diet counseling, preparation for parenting, and what to expect during labor, delivery, and postpartum. As
with all patient teaching, more than this content must be considered. Especially in this phase of lifespan
development, patient teaching may need to include a high degree of emotional support and awareness of barriers
interfering with adherence to those recommendations that are crucial not only to the patient’s own health, but
also to the growth and future development of her infant.

Patient Teaching with Parents when Children are Patients
When the patient is a child, he or she should be included as much as appropriate for his or her age level in the
teaching process. The fact remains, however, that in most instances it will be the child’s parents who will
supervise the degree to which recommendations for preventive health practices and/or treatment
recommendations are followed. The health professional’s ability to work effectively with parents is crucial to the
effectiveness of the patient teaching interaction.

Health professionals conducting patient teaching must establish rapport not only with the child as the patient,
but with the parents as well. Not only must the child’s learning readiness be assessed, so must the parents’. In
preparation for patient teaching, the health professional should assess the quality of relationship between parent

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and child and take the relationship into account during teaching interactions. Although some parents are open
and honest with their children, and foster independence, others do not. Some parents provide structure and
guidance while allowing their children the latitude to make some choices of their own, whereas other parents are
rigid and controlling, allowing their children little freedom of thought or expression. In other instances, parents
provide little structure or guidance, practice little rule enforcement, and essentially abandon the child emotionally.
Therefore, the approach the health professional takes to patient teaching in each of these instances will differ.

Child-rearing practices can be a source of conflict and controversy. Rather than being critical, health
professionals should use the relationship between the child and parent to its maximum advantage for patient
teaching to be most effective.

In addition to the parent–child relationship, the degree of parent involvement in patient teaching depends not
only on the cognitive ability and learning readiness of the child but also the ability of the parents to grasp the
concepts. This ability can be hampered by parents’ limited intellectual ability, their own degree of emotional
maturity and responsibility, and, in some instances, their level of anxiety. Some parents, although concerned and
well meaning, may have difficulty understanding information presented or directives that are to be carried out. In
this instance, health professionals should alter their approach to patient teaching to meet the parents’ as well as
the child’s ability to understand. When patient teaching is directed toward helping parents and the child learn how
to manage a chronic condition, health professionals should be sensitive to the parents’ perception of the child’s
condition, as well as the child’s reaction, and deal with their concerns and anxiety as much as possible.

Patient Teaching with Children as Patients
Although patient teaching with children usually involves the parent or caregiver as a recipient of information as
well as the child, health professionals should keep in mind that under these circumstances, the patient is still the
child. Consequently, health professionals should direct patient teaching to the child in an age-appropriate manner.

When initiating patient teaching with the child, health professionals should introduce themselves to the child
as well as to the parents or caregiver. To place the child at ease and to build rapport, health professionals should
engage in friendly conversation about topics of interest to the child. When talking with children, health
professionals should make an effort to speak with them at eye level. Children, just as adults, should be allowed
the opportunity to express their concerns, as well as to ask questions.

Because health recommendations given to a child necessitates involvement and cooperation of a caregiver,
health professionals should, as much as possible, present information in such a way as to establish a “team
effort” involving parent or caregiver, child, and health professional. Having an understanding of development of
children at different ages and what generally can be expected behaviorally and cognitively at each stage will
assist the health professional to tailor patient teaching to best meet the individual child’s needs.

AGE-SPECIFIC PATIENT TEACHING OF CHILDREN
Infancy
During infancy, patient teaching about the infant’s health and care is, of course, directed toward the parent or
caregiver. In most cases, patient teaching during infancy involves little time spent teaching about illness, unless
there are congenital problems or other issues that arise. Considerable time is spent teaching the parents about
development and about aspects of prevention and child care. In addition to helping parents learn what they
should expect from their infant developmentally during the first year of life, teaching about issues of prevention
such as infant safety and the importance of immunization are vital parts of patient teaching.

Infancy is a time of rapid growth and development (Gabbard, 2004). New parents may misinterpret many
normal aspects of infant development and may view these changes as a deviation from the norm. Helping
parents gain awareness of developmental milestones can help reduce parental anxiety and enable them to gain
increased confidence. Parents with little experience in child care may also experience insecurity in their ability to
care for their infant. Much of this can be alleviated by encouraging them to express their concerns, informing
them of what to expect, and helping them gain the knowledge and skills that will enhance their self-confidence.

Infant development, although occurring at a rapid rate, does not occur at the same rate for all infants. Unless
new parents are aware of this, they may experience anxiety when comparing their infant to other infants who
may be developing more quickly. Teaching parents about normal infant development, as well as the range of
individual differences, can relieve unnecessary anxiety and increase parents’ enjoyment in watching their infant
reach various milestones.

As the infant develops more physical skills, the importance of exploration of self and the environment
becomes paramount in stimulating further infant development. Patient teaching may also involve increasing the

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parents’ awareness of the importance of stimulation for their infant. Parents may be taught means of providing
stimulation at home, such as holding and talking to the infant, or hanging colorful mobiles above the crib.

An infant’s psychosocial development consists of building a basic trust that his or her needs will be met.
Parents should be helped to understand the importance of consistency in meeting their infant’s needs, but at the
same time they should be helped to learn how the infant’s schedule can gradually be adjusted to the parents’
schedule as well.

If patient teaching is to be effective, health professionals must consider affective as well as cognitive and
psychomotor aspects of patient teaching. Parent strain has an impact on the health and well-being of the infant
as well. Health professionals who are alert to clues indicating potential stressors can alleviate strain by providing
anticipatory information that may help prevent problems from occurring. In other instances, if problems already
exist, the health professionals can work with parents to find alternative solutions to reduce or alleviate the
problem.

In the context of family relationships, the health professional may need to reinforce the importance of the
couple finding alone time for themselves. If there are other children in the household, the health professional may
reinforce the importance of spending time with and giving other children individual attention as well. In the same
vein, talking with both parents can be an opportunity to emphasize the need for the new mother to have some
time alone away from the baby. Assessing the new mother’s emotional, as well as physical status, can alert the
health professional to potential areas of stress that can cause additional problems. Strain can be ameliorated if
health professionals address specific issues that arise, and reassure the parents that feelings of frustration in
caring for a newborn are normal, and experienced by many new parents.

Being aware of the insecurity of new parents, sibling rivalry, and other sources of parental stress helps health
professionals form an approach based on patients’ individual needs. Supplemental information can be given as
needed to alleviate stress and enhance the parents’ ability to carry out recommendations.

The Toddler
Like in infancy, development proceeds rapidly in the toddler years. Consequently, health professionals have
numerous topics of patient information that can be shared with parents. Information can be given during any
contact with parents and child. Unless an illness exists, much patient teaching at this life phase, in addition to
milestones of development, include aspects of prevention and safety.

Because many behavioral changes occur during this developmental phase, an important part of patient
teaching during this stage may be helping parents learn what to expect and how to respond to some of new
behaviors the child may be exhibiting. For instance, during the toddler stage, children can rapidly acquire
language skills. Health professionals can help parents foster this aspect of development by encouraging them to
talk with, as well as listen to, their child.

The toddler stage is also a time of increased autonomy, when toddlers recognize themselves as individuals
different from their mothers. Their newfound independence may be asserted through negativism, frequently
referred to as the “no” stage. Children in this stage may have difficulty making up their minds and may be prone to
temper tantrums. Such behavior can be a source of irritation for parents, especially if they fail to realize that such
behavior is common to children in this age group. Health professionals can teach parents about normal
development by helping them learn what behavior to expect as well as by teaching them what steps to take to
handle their toddler’s behavior. Teaching parents how to use appropriate and consistent techniques of discipline
and limit setting, without being overly restrictive, is an important aspect of patient teaching in this phase.

Another important aspect is child safety. As the toddler becomes more mobile—not to mention more curious
and more interested in exploring his or her environment—the risk of accident and injury increases. The health
professional should make the parents aware of potential safety hazards, and help them learn ways in which they
can reduce risk of injury by child proofing their home.

The toddler stage is also characterized by toilet training. Toilet training is commonly an emotional process in
which parents place considerable pressure on themselves and their child to perform. By teaching various ways to
implement toilet training and by emphasizing individual rates of development, parents may be helped to
accomplish the task with considerably less stress both for themselves and for their child.

Although most patient teaching will still be directed to the parents, children in the toddler stage are capable of
some degree of understanding the procedures they may experience. Health professionals should establish
rapport with the child through simple patient teaching that can also enhance cooperation from the child. The
health professional’s approach to the child should be warm and matter-of-fact. Although children at this age are
able to comprehend more words, they are still unable to reason, and may take things literally. Consequently,
explanations given to toddlers should be simple and accurate with no analogies.

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Early Childhood
Preschool children continue to develop their own identities and expand their world through involvement with
others outside the family unit. In previous stages, although the child might have played alongside another child,
there was little actual interaction between the two. In the preschool phase of development, children begin to
interact with each other in cooperative play. During this phase, the child also engages in imaginary play and may
develop imaginary playmates.

Health professionals’ interaction with preschool children and their families may be sporadic, occurring only
when there are medical problems or during standard child checkups. Every interaction is an opportunity to teach
parents not only about their child’s condition, illness, or medical recommendations if the child is ill, but about
health promotion and prevention, as well as to offer guidance and reassurance.

Children in early childhood begin to develop a gender identity in which they distinguish themselves as a boy or
girl and become aware of differences in the opposite sex. During this phase they also develop increased sexual
curiosity, resulting in questions or in behaviors such as masturbation. A child’s sexual curiosity may bring about
anxiety in parents who do not know how to respond to their child’s questions or who question whether their
child’s sexual curiosity and behavior are normal. Health professionals can facilitate the parents’ understanding
and acceptance of their child’s sexual curiosity by reassuring them that such interest and activities are normal
parts of development and by teaching parents ways to respond to their child’s questions by using simple,
straightforward responses that are presented in a relaxed manner.

In recognizing approaches to children at this age, health professionals facilitate communication between
parent and child as well as their own relationship with the children. Children have a vocabulary of approximately
2000 to 2500 words by the time they are 5 years old. Teaching children about procedures to be performed should,
therefore, become a routine part of the interaction with children as patients. Although the preschool child has
developed a fairly extensive vocabulary, they may be unable to recognize someone else’s point of view.
Consequently, at this developmental phase, explanations should focus on simple facts rather than attempting to
reason with the child as to why he or she should follow a recommendation or have a procedure performed.
Because children at this phase fantasize, they are quite vulnerable to fear of pain and bodily harm. It is important
to acknowledge children’s fears and help them to express their fears openly while providing reassurance. At the
same time, however, it is important that explanations continue to be honest with no false promises that could
erode the child’s trust in the future.

Middle and Later Childhood
During this phase of development, health professionals are increasingly able to establish a one-to-one
relationship directly with the child as a patient. At this stage, although there will still be some input from parents,
children are capable of reporting symptoms fairly accurately. They …

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capable of concrete, logical reasoning. Including children in patient teaching, especially about procedures,
becomes even more important as they increase their ability to comprehend. Health professionals should explain
procedures, as well as the reasons for them, in a simple, logical way and with confidence and optimism, although
explanations should also be realistic in helping the child understand what to expect.

Health professionals will, of course, still spend considerable time teaching parents. In addition to teaching
them about the child’s illness and treatment plan, parents may also be encouraged to foster the child’s
independence and to praise his or her accomplishments. During middle to late childhood, children develop
physical prowess; however, their ability to make sound judgments lags behind, and as a result, the potential for
injury is high (National Center for Injury Prevention and Control, 2003). Consequently, considerable patient
teaching might be devoted to teaching about safety issues and how to prevent injuries.

Specific problems arising during this phase of development that may come to the health professional’s
attention are behavior disorders, hyperactivity, learning disorders, and enuresis. Any of these problems may
cause stress for the child as well as the family and may require extensive teaching to enhance both the parents’
and child’s understanding of the condition and the methods to be used in dealing with it.

In all stages of childhood, when patient teaching is provided because of illness, it is important to keep the
child’s developmental stage in mind, and to encourage parents to foster the child’s normal development despite
limitations that may be imposed by illness.

Adolescence
Adolescence is a phase of development that marks a transition cognitively, socially, and physically from
childhood to adulthood. Understanding characteristics of the adolescent phase of lifespan development is
crucial in order for patient teaching to be effective. Adolescence is a time of marked change. Adolescents are in
the process of forming their own identity, emancipating themselves from their parents, and adapting to a rapidly
changing body. Because adolescents are capable of abstract thought and reasoning, they are capable of
comprehending most explanations given as part of patient teaching.

Although the adolescent’s family may still be included in some aspects of patient teaching, the adolescent
alone is the major focus of patient teaching because at this stage they have considerable independence and are,
consequently, in more control of the degree to which recommendations will be carried out. Considerations of the
family and solicitation of its support in helping the adolescent patient following recommendations is important;
however, building a relationship with the adolescent and facilitating the relationship between the adolescent and
his or her family is perhaps more important now than at any other time in order to increase the likelihood of
adherence with recommendations.

Patient teaching needs of the adolescent are wide and varied, and extend beyond the teaching that may be
involved when there is illness or injury. Although adolescents have increased potential for abstract thought and
the ability to reason, they lack life experience and may have difficulty making rational decisions. Consequently,
teaching and guidance regarding a number of issues has increased importance. Adolescents have difficulty
imagining that they can become sick or injured and subsequently have increased potential for engaging in risky
behavior, which may make them more vulnerable to injury and accidents, experimentation with drugs or alcohol,
and sexually transmitted diseases and unwanted pregnancy (Centers for Disease Control and Prevention [CDC],
2006).

Because of adolescents’ strong need for peer acceptance and support, health recommendations that they
view as interfering with their concept of themselves as independent beings, or that they feel would set them
apart from their peers, may be less likely to be followed. In addition, as part of their need to establish themselves
as independent individuals, adolescents may rebel against authority and become disillusioned with parents or
other authority figures. This can also interfere with adherence to health recommendations—whether those
recommendations are related to management of disease, recovery from injury, or preventive health measures.

Rapid body changes that occur during adolescence can bring about a strong preoccupation with body and
appearance. Sexual adjustment is an important part of adolescent development. During this time, adolescents
experience a strong desire for sexual exploration and to express sexual urges. Sources of information available
to them about sexual issues may be weak and misleading, obtained from movies or peers, rather than reliable
sources. Parents may not know how to talk with their adolescent child about sexual matters, and sex education
in schools, if existent, may be inadequate. Although discussion of sexual issues with adolescents has been
feared by some to promote sexual activity, comprehensive information about sexual issues has not been found
to increase adolescents’ sexual activity, but has been found to decrease it (McElderry & Omar, 2003; Weaver,

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Smith, & Kippax, 2005). Consequently, sexual health issues are an important part of patient teaching during
adolescence. Teaching adolescents about sexual issues requires a special sensitivity and understanding.
Regard for the adolescent’s modesty and privacy is important in providing an atmosphere of openness and trust
so these issues can be addressed.

Adolescents’ tendency to engage in risk-taking behaviors, their lack of experience, and their tendency to
become distracted contribute to a higher rate of injury during this life phase. For instance, vehicle accident rates
for adolescents are higher than for any other group (National Highway Traffic Safety Administration, 2006). In
addition, because of the adolescent need to be part of a group, difficulty with judgment, tendency toward risk
taking, and the potential for drug and alcohol use during adolescence increases dramatically (Substance Abuse
and Mental Health Services Administration, 2004). Patient education programs that simply provide factual
information about the dangers of drugs have shown little impact on drug use, and have actually been found to
increase drug use in some instances because of curiosity arousal (Botvin & Griffin, 1999). More effective patient
teaching about substance use includes addressing many other issues in the adolescent’s life that may
contribute to drug use. Patient teaching should include helping adolescents to learn life skills that help them
achieve positive goals, and help them learn how to resist peer pressure to use substances or take risks
(Montoya, Atkinson, & McFaden, 2003; Robertson et al., 2003).

Numerous other issues are potential topics of patient teaching during adolescence. For instance,
adolescents develop at different rates that can cause stress and concern. Teaching adolescents about individual
differences and offering reassurance to those adolescents who mature either “too late” or “too early” in
comparison with their peers can help them increase self-esteem, and adjust in the transition to their next phase
of development.

No matter what the topic, the likelihood that patient teaching will be effective is higher if an atmosphere of
trust has been established by respecting adolescent needs and showing empathetic understanding. Patient
teaching should take on the form of guidance, not lecturing. Adolescents should be treated neither as adults nor
as children; however, as with all patients, the approach to patient teaching should be modified to meet the
specific needs of the individual.

Although the family of the adolescent should also be considered and included in patient teaching when
appropriate—especially when illness or injury are involved—a health professional who wants to gain credibility
with an adolescent must establish himself or herself as an advocate of the adolescent rather than as a
representative of the parents. Although much patient teaching is conducted directly with the adolescent, health
professionals may also provide guidance and support to family members, and help them to understand
adolescent behavior. Parents should be encouraged to set realistic limits for adolescents while, at the same
time, fostering their independence. Adjustment to an adolescent’s gradual independence may be difficult for
parents, who must now also begin to redefine their role as parents. Patient teaching with adolescents can be
enhanced if health professionals can identify potential sources of stress in the family and support parents in
their own readjustment. Because of the ambivalence of the stage between childhood and adulthood, health
professionals should be aware of the importance of considering both adolescents and their parents when
conducting patient teaching.

When conducting patient teaching with adolescents about illness or injury, the same characteristics of this
stage of lifespan development that impact issues of prevention may also impact an adolescent’s receptiveness
to information and adherence with recommendations for management of his or her condition. Adolescents need
to establish themselves as independent individuals; the need for peer inclusion, as well as changing body image
and belief in immunity from consequences of behaviors, may impact the effectiveness of patient teaching. The
consequence of nonadherence is, of course, a result of the seriousness of the illness or condition for which the
adolescent patient is being treated. In any instance, health professionals who are concerned about effective
patient teaching must consider and include issues that are part of this stage of development, altering their
approach to meet the adolescent patient’s needs.

TEACHING ADULTS THROUGHOUT THE LIFESPAN
Young Adulthood
Because developmental changes are individual, occur gradually, and continue throughout young adulthood,
moving from adolescence to adulthood is not clearly demarcated. Challenges associated with this stage of
lifespan development include selecting and building a career, adjusting to work life, establishing relationships,
establishing and maintaining a home, and perhaps beginning a family. All of these challenges may provide
opportunities for patient teaching. Awareness of change occurring in the patient’s life, and his or her reaction to it
may provide cues that specific aspects of patient teaching should be initiated. For instance, when a patient
engages in an intimate relationship, there may be a need for patient teaching about contraception or safe sex

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practices. If a patient becomes pregnant, prenatal teaching, newborn care, and numerous other topics related to
child care need to be covered during the next years of interaction. Although many challenges associated with
young adulthood can be happy events, they can also be a source of stress. Recognizing potential stressors,
assessing the level of stress the individual is experiencing and their reaction to it, provides the health
professional with information that not only helps him or her determine the approach to patient teaching, but
information that helps determine specific content areas that may need to be addressed. Identifying the
significant people in the patient’s life can also help the health professional determine the degree to which these
relationships are available as support for carrying out recommendations, or the extent to which they may hinder
the individual’s ability or willingness to adhere to recommendations. Health professionals should refrain from
making assumptions. Questions about patients’ significant others should be approached in a direct, neutral, and
sensitive way. Not all patients have positive or supportive relationships with family or friends, even when they are
present. Likewise, not all patients live in a traditional, nuclear family setting. A variety of living arrangements,
alternative lifestyles, and close family bonds may be present even though the relationships are not legalized by
marriage, adoption or guardianship, or are not determined by heredity.

Data suggest that 4 to 9% of the population is in same-gender relationships (Harrison & Silenzio, 1996).
Although an increasing amount of individuals are more open now about being in a same-gender relationship,
there are still many individuals who remain reluctant to acknowledge their preference or their relationship
because of fear of discrimination or, in some instances, fear of physical or emotional abuse (Greco & Glusman,
1998). Consequently, patients may not always be forthcoming about sexual preferences. Making assumptions
about individuals’ lifestyle or sexual preference, or who they consider as their major source of emotional support
without checking with patients themselves not only serves to alienate patients, but can also cause missed
opportunities for patient teaching.

Patients with same sex preferences have the same patient teaching needs in all aspects of their lives as do
individuals who are in traditional relationships. Pregnancy, parenthood, job stressors, sexual issues, prevention
practices, or illness management are situations that offer potential patient teaching opportunities for all patients,
regardless of sexual orientation. All patients should be approached in an open, nonjudgmental way that helps the
health professional build rapport and trust with the patient. As with all patients, frank and open discussion helps
health professionals determine patient teaching needs. Patients who trust their health professional are more
likely to follow given recommendations (Greco & Glusman, 1998).

Although individuals can become ill at any age, the leading causes of death, illness, and disability in young
adulthood are related to behavior (Hoyert, Kung, & Smith, 2005; Poole, Warren, & Nunez, 2007). For instance, in
young adults, vehicle accidents are often associated with speeding and alcohol use, and a number of chronic
illness are associated with smoking, lack of exercise, and poor diet (Marks et al., 2000). Obesity has become an
increasing problem in all age groups, and places young adults at risk for many chronic conditions including high
blood pressure, heart disease, diabetes, and arthritis-related disabilities (Poole, Warren, & Nunez, 2007).

Health promotion issues, although often neglected, may be especially important to address during young
adulthood. Stress may contribute to further illness and poor coping practices such as alcohol or drug use. Much
of the individual’s future health may be determined by health practices established now. Helping patients learn to
cope with stress, talking with them about health risk factors, and helping them establish good health practices
may all be important in preventing many of the health problems that may otherwise occur in the future.

Patients’ cultural and economic circumstances may determine their ability to follow recommendations
regarding healthy lifestyle. In addition, some environments are more stressful than others. For instance, violence
is one of the major threats to health during young adulthood (CDC, 2006). Although no one is immune to being a
victim of violence, rates of violence tend to increase for groups with lower socioeconomic status (Reiss & Roth,
1994). When conducting patient teaching about prevention, it is important that the health professional be
sensitive to the patient’s particular life circumstance and conduct patient teaching in the context of the
individual’s particular situation.

Knowledge of all aspects of an individual’s life helps health professionals determine the type of patient
teaching most relevant to the patient’s circumstances as well as helping to identify supports and barriers to their
following treatment recommendations. Financial constraints, family responsibility, cultural differences, and work
schedule may all be common factors in this stage that can influence an individual’s ability to adhere to
recommendations.

Middle Adulthood
Just as adolescence is the link between childhood and adulthood, midlife is a transition period between young
adulthood and the later years. During these years, many individuals have reached the peak in their career. They
may also begin to reexamine and question former goals and values as well as their perceived degree of
achievement. During this personal assessment, people may begin to modify aspects of their lives that they

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consider unsatisfactory. They may begin to adopt a new life structure that is perceived as a solution to the
dissatisfaction they may be experiencing.

Physical changes of aging may begin to be more apparent. Individuals may begin to notice some decrease in
physical stamina, changing hormonal levels for women result in menopause, and vision and hearing acuity may
begin to decrease. In addition, individuals become more aware of their own vulnerability to certain illnesses
during middle adulthood. Discussion of hormone replacement therapy and calcium supplements may be
particular patient needs for women who are concerned about the potential for developing osteoporosis.
Cholesterol levels and the potential for developing heart disease may also be of concern to patients. The need for
routine screening, such as mammography or colonoscopy, for early detection of cancer may be issues included
in patient teaching. Teaching about basic practices in health promotion and their role in disease prevention may
be even more relevant at this life stage. In addition, individuals may develop issues or questions about their own
sexuality as they age. Sensitive and open discussion can help individuals address their concerns regarding these
issues. Patient teaching about physical changes and management can help individuals make adjustments to
changes they are experiencing, and incorporate behaviors that will help them maintain their health.

Those in the middle adult phase of lifespan development, if in a family group, may find themselves
reappraising not only their marital relationship, but the relationship with their children as well. As their offspring
begin to leave home and establish their own families, parents need to adjust their roles. At the same time, people
in middle adulthood may grow increasingly responsible for their parents, whose own health may be failing.
Recognizing their own physical changes, their parents’ declining health, and their own goals and values, middle-
aged people may become especially aware of their own mortality. This realization may either motivate the
individual to follow recommendations more closely or, if the prospect of mortality is especially threatening, to
deny illness or abandon health promotion and prevention practices.

Depending on the individual’s situation, there may be many areas of stress and a variety of reactions that can
contribute to illness behavior as well as act as barriers to effective patient teaching and, consequently, barriers to
recommendation adherence. Health professionals should be aware of potential problems and approach patients
with a nonjudgmental attitude. In addition to teaching about specific medical recommendations, teaching should
also include health risk factors, stress reduction, and identification of misconceptions or misinformation that
may be present. Misconceptions regarding physical changes such as menopause and other changes may be
especially prominent. Helping people in midlife cope with stress can enhance teaching and enable patients to
live happier, healthier, and more productive lives. As with all other life stages, the health professional should be
aware of potential sources of stress associated with this age as well as particular circumstances of the
individual’s life and how these factors may impact the type of patient teaching required. The health professional
should also consider how these factors impact the patient’s ability to follow recommendations.

Later Adulthood
Although many older adults remain healthy and active in later life, the incidence of chronic diseases increases
with age for many people. As a result, much patient teaching may revolve around illness and disease with
aspects of prevention being neglected. Health professionals may have had little formal training regarding
approaches to the older adult, and may therefore be uncomfortable with patient teaching. Attitudes of health
professionals as well as inadequate understanding of later life stages may well be the greatest barriers to
effective patient teaching for this group. Working with older patients may elicit fears in health professionals of
their own aging and death; therefore, interaction with older patients may be avoided. Health professionals may
believe myths about aging and approach older adults with those stereotypes rather than approaching them as
individuals. Patient teaching with older patients can, however, be of great benefit to the patient and rewarding to
the health professional as well.

Many older patients may be coping with various degrees of loss. Older adults may be facing retirement and
adjustment to a new lifestyle. Others may retire and return to the workforce after they have left a career.
Retirement may be a source of satisfaction or anxiety, depending on the circumstances. Economic issues, health
issues, individual factors, and family issues all contribute to the degree of stress or satisfaction an individual
experiences.

Family situations also vary greatly in older adulthood. Individuals may have lost a spouse, may have never
married, or may be divorced. They may be active with their partner or friends, or they may be the sole caretaker of
an ill spouse or partner. They may have adult children they are close to or from whom they are estranged.
Grandchildren may be a joy and diversion, or may be the source of stress if the patient needed to assume the
responsibility for their care.

As individuals age, they may also experience increasing losses such as friends or their own physical
capability. As individuals reach the later stages of this phase of lifespan development, physical decline becomes

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more rapid. Depending on the degree of loss present, there may also be decreased independence, with resulting
loss of self-esteem and self-satisfaction.

Health professionals conducting patient teaching with patients in later adulthood should realize that
individuals are diverse and this group can include healthy, alert individuals who may have some physical
limitations, but still enjoy life and continue to have an interest in learning how to stay active as long as possible,
manage their condition, and prevent further disease, complications, or disability from occurring. Health
professionals should approach each patient without stereotypes or preconceptions. As in all other life stages,
not all changes of aging occur at the same rate, and not everyone in the same age group has the same
experience or life circumstances. Aging should be viewed as a multidimensional process in which the individual’s
function and health status are related to multiple factors. When conducting patient teaching, the health
professional should treat older adults as individuals and with the same interest and respect as any other patient
with whom patient teaching is being conducted. For instance, health professionals should not use first names in
teaching interactions with older adults unless invited to do so. Patient teaching with older adults should be
conducted with the same conviction with which it would be delivered to patients at any other age.

When conducting patient teaching with individuals who have altered hearing acuity, health professionals
should position themselves close to the patient and speak clearly and concisely, remembering that raising the
loudness of the voice does not necessarily contribute to the listener’s better hearing. Patient teaching should be
realistic but hopeful. Pat phrases, such as, “What do you expect at your age?” or “You’ll live to be 100,” are
inappropriate and should be avoided.

Patient teaching need not be confined to illness with older individuals anymore than it is with younger
patients. Issues to be addressed in addition to those that deal with specific illness or treatment
recommendations might include sexuality, exercise, nutrition, and a variety of other topics that are oriented
toward prevention of illness or disability and toward the enhancement of the quality of life.

Barriers to independence should be assessed to help the patient find ways to maximize strengths and
independence. Older patients should be helped to learn how to make optimum use of their skills and functions.
Because of problems that may exist in this life phase, health professionals should be especially aware of
adherence problems due to misunderstanding, physical limitations, or financial barriers. Health professionals
may be able to enhance patient ability to follow medical recommendations by providing information, considering
patients’ individual needs, and building an awareness of community services and resources that can help them
follow given recommendations.

A LIFESPAN PATIENT-CENTERED APPROACH TO PATIENT TEACHING
Knowledge about lifespan development has obvious relevance for health professionals conducting patient
teaching. In order to conduct effective patient teaching, patients must be understood in the context of their
particular situation and circumstances. This includes not only physical, psychosocial, and social circumstances,
but also the particular stage of life they are experiencing along with the specific challenges related to that stage.

Throughout life, people experience challenges at different stages that lead to a variety of changes. These
challenges, and resulting changes, influence an individual’s attitudes, perceptions, actions, and behaviors.
Although developmental changes may be more apparent in childhood, such changes occur in adulthood as well.
Knowledge of changes that can occur at various points during the lifespan enhances the health professionals’
ability to teach effectively, as well as helps them identify topics that may be presented to patients along with
specific recommendations related to the patient’s illness. Opportunities for patient teaching exist regardless of
illness or injury. Examples of health-related topics that may be covered at various life stages are illustrated in
Table 5-1. The list, although not all-inclusive, points out a variety of topics that may be discussed whether or not
the patient is seeking advice for a health problem.

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Table 5-1 Patient Teaching Issues Through the Lifespan

Prenatal Period Normal changes associated with pregnancy, both emotional and physical;
sexual activity during pregnancy; preparation for the newborn; diet counseling;
preparation for the role of parenting; process and procedures during labor,
delivery, and postpartum

Infancy Normal infant development; individual differences; immunizations; infant
stimulation; infant feeding; safety issues; teething; family interactions

Toddler Child development; safety; toilet training; discipline and setting limits; nutrition

Preschool-aged Children Importance and role of play; dealing with sexual curiosity and questions;
general health practices; school adjustment; sleep problems

Adolescence Normal development patterns and individual differences, emotional and
physical; sex education; skin problems; nutrition and other health practices;
safety; drug and alcohol use

Young Adult Stress reduction; health maintenance and promotion; intimate relationships
and adjustment; prenatal teaching; child-rearing practice

Middle Adulthood Physical changes, such as menopause; health risk factors; changes in family
relationships; stress reduction; health promotion

Later Adulthood Adjustment to retirement; nutrition and exercise; adaptation to loss;
modification of environment to promote independence as necessary;
sexuality

During early phases of the life cycle, most patient teaching is conducted with parents rather than children
themselves. As the individual moves through the life cycle, more interaction will obviously occur directly between
the patient and the health professional. Although health professionals should always approach each patient as
an individual, knowledge of general human characteristics at various stages of development can be helpful.
Table 5-2 offers suggested approaches for use with patients at various stages of development to make the
teaching interaction more effective.

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Table 5-2 Patient Teaching Approach Through the Lifespan

Lifespan phase Approach of Health Professional

Prenatal Parents: Use an open-minded approach with no preconceptions;
nonjudgmental; give emotional support to both parents; work
within parents’ framework

Infancy Parents: Foster security by giving positive feedback regarding
parents’ ability to care for the child; no nagging or lecturing; take
what may appear to be small problems seriously

Toddler Parents: …

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REFERENCES
Botvin, G. J., & Griffin, K.W. (1999). Preventing drug abuse. In A. J. Reynolds, H. J. Walberg, & R. P. Weissberg (Eds.), Promoting positive outcomes

(pp. 197–228). Washington, DC: Child Welfare League of America.
Broderick, P. C., & Blewitt, P. (2006). The life span: Human development for helping professionals (2nd ed.). Upper Saddle River, NJ: Pearson/Merrill

Prentice Hall
Centers for Disease Control and Prevention. (2006). Health topics. Retrieved June 27, 2009, from

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Gabbard, C. P. (2004). Lifelong motor development (4th ed.). San Francisco: Benjamin Cummings.
Greco, J. A., & Glusman, J. B. (1998). Providing effective care for gay and lesbian patients. Patient Care, 32(12),159–162, 167–168, 170.
Harrison, A. E., & Silenzio, V. M. B. (1996). Comprehensive care of lesbian and gay patients and families. Primary Care, 23, 31–46.
Hoyert, D. L., Kung, H. C., & Smith, B. L. (2005). Deaths: Preliminary data for 2003. National Vital Statistics Reports, 53(15).
Marks, D. F., Murray, M., Evans, B., & Willig, C. (2000). Health psychology: Theory research and practice. Thousand Oaks, CA: Sage.
McElderry, D. H., & Omar, H. A. (2003). Sex education in the schools: What role does it play? International Journal of Adolescent Medicine and Health,

15, 3–9.
Montoya, I. D., Atkinson, J., & McFaden, W. C. (2003). Best characteristics of adolescent gateway drug prevention programs. Journal of Addictions

Nursing, 14, 75–83.
National Center for Injury Prevention and Control. (2003). Childhood injury fact sheet. Retrieved June 26, 2009, from

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National Highway Traffic Safety Administration. (2006). Saving teenage lives, Section I: Introduction: The need for graduated driver licensing.

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Osofsky, J. D., & Thompson, M. D. (2000). Adaptive and maladaptive parenting: Perspectives on risk and protective factors. In J. P. Shonkoff & S.

J. Meisels (Eds.), Handbook of early childhood intervention (2nd ed., pp. 54–75). New York: Cambridge University Press.
Poole, D., Warren, A., & Nunez, N. (2007). The story of human development. Upper Saddle River, NJ: Pearson/Prentice Hall.
Reiss, A. J. Jr., & Roth, J. A. (Eds.). (1994). Understanding and preventing violence, Vol 3: Social influences. Washington, DC: National Academy

Press.
Robertson, E. B., David, S. L., Rao, S. A., & National Institute on Drug Abuse. (2003). Preventing drug use among children and adolescents: A

research-based guide for parents, educators, and community leaders (2nd ed.), Bethesda, MD: National Institute on Drug Abuse.
Substance Abuse and Mental Health Services Administration. (2004). Results from the 2003 national survey on drug use and health:. National

findings. Office of Applied Studies, NSDUH Series H-25, DHHS Publication No. SMA 04-3964.
Weaver, H., Smith, G., & Kippax, S. (2005). School-based sex education policies and indicators of sexual health among young people: A

comparison of the Netherlands, France, Australia and the United States. Sex Education, 5, 171–188.

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CHAPTER 6

The Family, Patient-Centered Teaching, and Patient
Adherence

ROLE OF THE FAMILY
Patients rarely exist in a vacuum. Family, friends, and other relationships a patient may have all play an important
role in the patient’s life and health. A patient’s significant other affects not only the patient’s health behaviors, but
also his or her ability to cope with illness and the degree to which they adhere to recommendations (Mannes et
al., 1993). Patient beliefs and attitudes about health, lifestyle, and health care begin at home with the family
(Lipkin, 1996). Many of the health practices and beliefs patients hold stem from what they have been told, have
experienced, or have observed as part of their family system. It should be obvious then, that the family has
considerable influence on a patient’s health practices and, consequently, should be an important aspect of
effective patient teaching in healthcare settings.

As a patient’s primary support system, family can affect a patient’s decision making about health and health
care. Families often help patients make decisions about how and when to enter the healthcare system, whether
entry involves emergency care or care for acute or chronic disease, or for general health maintenance (Reust &
Mattingly, 1996). Families may also influence the extent to which patients follow recommendations. These
influences can affect whether or not patients take their medication, follow the prescribed diet, have
recommended diagnostic tests or surgical procedures, or even determine end-of-life decisions or nursing home
placement (Jecker, 1990). Family members may also assist by providing the patient with functional support in
which they help the patient carry out certain tasks as part of the treatment recommendations, or provide
emotional support (Shirey & Summer, 2000). Understanding how family contributes to patient ability or
willingness to follow recommendations given by health professionals can be a valuable asset in conducting
patient teaching.

Although consideration of the individual is important in patient teaching, the patient’s family is also of central
importance if teaching is to be effective. Consequently, not only should patient teaching be patient-centered, it
should also be family-focused (Clark & Dunbar, 2003). For the individual patient, the family constitutes the social
context in which illness occurs. Illness and treatment affect the family as well as the patient. When a family
member becomes ill, the illness alters the context of daily living and requires additional time and energy from
family members. Illness can disrupt employment or school patterns of family members and cause financial
hardships. In addition, illness and treatment can enhance or threaten family relationships, or alter the roles its
members play (Reust & Mattingly, 1996).

Likewise, the family contributes to the health and health behavior of the patient. The happiness and health of
each individual family member depends, to a significant degree, on the nature of his or her interaction with other
members in the family unit. How a family functions influences the health of its members as well as how an
individual reacts to illness. Teaching the patient without considering the family may result in less-than-adequate
adherence with recommendations. Family functioning, family support, problem solving, communication, and self-
efficacy all contribute to and influence the degree of assistance and support the patient receives (Dunbar et al.,
2008). The ability of the health professional to teach the patient how to maintain or restore health depends on his
or her insight into the patient’s relationship with family members, as well as other family issues. Consideration
should be given to the extent to which family members can help the patient in terms of offering assistance,
support, and encouragement. The health professional should attempt to include the family in patient teaching.
For instance, what good does it do to teach a middle-aged man about his diet if his wife does all the cooking and
is excluded from patient teaching about dietary restrictions? Likewise, it may be difficult for a husband to be
supportive of his wife’s blood pressure treatment program if he does not understand the reasons for the
recommendations and the consequences of not carrying them out.

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It is important to consider the influence of family members on the patient’s health behaviors, and to include
them in patient teaching as appropriate; however, it is also important to not make assumptions. The health
professional should remember that not all patients want their families involved, and even when they do, not all
families can meet expectations of health professionals. Not all patients receive the support and encouragement
needed from their families and not all families have the emotional stability to cope with long-term illness. If the
relationship between family members was not stable before the patient’s illness, or if the relationship was
strained, the additional stress of illness may cause even more problems. In other instances, family members
may have conflicting obligations. They may have other responsibilities to fill in addition to their roles within the
patient’s family unit, and some roles and obligations may conflict with the patient’s needs. For example, children
of an older patient may have families of their own. Although they may feel concern and responsibility for their
aging parent, the health professional cannot realistically expect that they will sacrifice their own family to help
their aging parent carry out all treatment recommendations.

Long-term illness, even in the most stable of family units, is bound to bring about changes in family
relationships. Illness itself changes the patient’s role within the family. Such change naturally produces some
disequilibrium within the family structure until adjustment occurs. For instance, if the head of the household and
chief breadwinner has been the husband, a disabling illness that prevents him from working may change his role
in the family. His wife may have to assume the role of chief breadwinner while he assumes the role of a
dependent. If the health professional does not recognize this change, what the change might mean to the patient
and family, and how it might affect the patient’s willingness and ability to carry out the recommendations, the
effectiveness of patient teaching may be diminished.

When teaching the patient and family, it is important for health professionals to identify patterns of
relationships and to be alert to attitudes of family members. Health professionals may also be able to identify
resources within the family group and help family members mobilize their resources to help the patient.

When gaining support from family members to facilitate the patient’s ability to follow recommendations,
health professionals must also remember that family members are just that—family members—and not health
professionals. The purpose of involving families in patient teaching is to gain their support by helping them to be
better informed, not to prepare them as spies to monitor the patient in the health professional’s absence.

When conducting patient teaching with the patient’s family, it is important for health professionals to be
aware that the same barriers that may interfere with effective teaching with the patient can also exist with
individual family members. Family members have their own personality style, coping methods, values, beliefs,
and other psychosocial variables that must be considered. For instance, illness in a family member tends to raise
the anxiety of those who are close to the patient. Anxiety may be misinterpreted by the health professional as
lack of interest or as reluctance on the part of the family member to provide the patient with help and support. In
other instances, a family member’s method of coping may be to deny the seriousness of the patient’s illness or
the importance of following recommendations. The more health professionals can be aware of these reactions
and help family members deal with their feelings, the more effective the health professional will be in teaching
family members about the patient’s condition and treatment, as well as in mobilizing their support.

Although it is important to understand how devastating illness can be to a patient, it is also important to
understand that illness causes strain on the family as well. If the family is already under stress, illness will
probably subject both patient and family to additional emotional pressures. Information about the family function,
stress, transition, and expectations can be invaluable in developing the most effective teaching plan for patient
and family alike. Although the major focus of the health professional’s attention is on the patient, the impact of
the family on the patient’s receptivity to information, as well as ability and willingness to follow treatment
recommendations, must also be considered.

FAMILY STRUCTURE AND STYLE
Commonly, most health professionals think of family in terms of the nuclear family—a group in which there are
parents and children—or in terms of the extended family—which includes parents, children, grandparents, aunts,
uncles, and the like. Today, family extends beyond the traditional family boundaries and includes those
individuals who the patient looks to for assistance and support, and considers emotionally close and most
influential in their life, regardless of whether legal or blood ties exist. People’s emotional effects on one another
need not be limited to blood relations. If perceived this way, a family might include two people living together with
or without sexual attachment, single-parent families, remarried families with children and/or stepchildren, and a
host of other family forms. Rather than viewing the family in only the traditional manner, expanding the definition
of family may be important when developing a teaching plan for the patient.

The family is the social network in which each individual has a specific role and from where the patient
derives at least some of his or her identity. It is also the network with which the patient has strong psychological

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bonds. The family influences health behavior through interactions and reactions, through past experiences and
attitudes, and through the family’s relationship to the community in which its members live. For example, an
individual whose family is in a socially isolated, rural area will probably hold different attitudes and perform
different practices of health and illness behavior than individuals whose families live in a suburban metropolitan
area. The child whose father is a physician will probably have different reactions and attitudes toward health and
health care than the child whose father is a farmer.

Not all families function the same way, nor do all families have the same structure or style. As each individual
in the family unit goes through his or her own stages of development, the structure, composition, and role of the
family change. As a result, the family as a whole goes through different stages of development. Just as illness
may have a different impact on individuals at different phases of development, so may it have a different impact
on families at different developmental stages. For instance, illness of a spouse or partner in a newly formed
family union without children has a different impact than it might have for a middle-aged couple with children
they are sending to college, and would have yet a different impact for a couple in old age. Awareness of the
impact at different family developmental stages helps the health professional approach patient teaching in a
way that maximizes the potential for effective patient teaching.

Determining who the patient looks to for support in the family can be accomplished by talking with the patient
and by observing family interactions. Who does the patient talk about most? What is the patient’s reaction when
talking about his or her family and the individuals in it? Who comes to visit the patient in the hospital? Who
accompanies the patient in an outpatient setting? What is the interaction between the patient and individual
family members like? What sources of stress were family members experiencing prior to illness as a result of
their developmental stage?

Illness in a newly formed family, for example, may cause additional strain because of economic
considerations, interruptions in career development, and/or adjustment to the new relationship itself. If the
patient is a young child, there may be additional strain to the family if there are other children whose needs also
must be met. Illness in the middle stage of family life, when adolescents are attempting to emancipate
themselves from family ties at the same time their parents are experiencing their own midlife transitions, may
place further strain on what already is a tumultuous time for the family. Illness in either parent or child may
interfere with the mutual weaning process that should be occurring at this stage. Illness in later age may not only
have an impact on grown children, but may also occur when the older couple had anticipated a time of enjoyment
together and are less able to care for each other as a result of their own physical limitations that may be
associated with aging.

Health professionals will be more effective in patient teaching if they are able to identify the family’s
predominant lifestyle and find ways to sustain and incorporate recommendations into it rather than trying to
impose a different pattern. For instance, some families exhibit a high degree of structure, while others exhibit
little structure and appear to be in a constant state of chaos. When aware of the system by which the family
operates, health professionals can work within the system rather than trying to fight it. Again, the most effective
patient teaching is that which fits into the patient’s frame of reference and with which the patient feels most
comfortable.

If health professionals can identify relationship patterns and attitudes within the family unit, these factors
can be incorporated into patient teaching. These factors can then at least be considered when estimating the
patient’s potential for following recommendations. An example of family influence is illustrated by the following
case.

Mrs. Roberts was pregnant with her first child. She and her husband lived in the same small community in
which they had grown up, and their extended family was quite large. Mrs. Roberts regularly attended prenatal
classes offered at the local hospital. At one session, the topic was breastfeeding versus bottle feeding. The pros
and cons of each were discussed. It appeared to Mrs. Roberts that there were obviously more benefits to the
infant from breastfeeding than bottle feeding.

At her next prenatal visit, she discussed breastfeeding with her physician, and it was agreed that she would
breastfeed her infant. After the birth of her baby, Mrs. Roberts had considerable difficulty breastfeeding. After 2
weeks, she visited her physician, stating that she would have to bottle-feed instead. She was obviously upset,
perceived herself as failing, and worried that the transition from breast to bottle would affect her infant. The
nurse in the physician’s office took time to talk with Mrs. Roberts about her feelings and discovered that Mrs.
Roberts’ mother and mother-in-law had both been quite opposed to her breastfeeding, feeling that in their day
breastfeeding had been done out of necessity. They were anxious for their children to have it easier than they did
and strongly encouraged the use of modern conveniences—in this case, premixed formula. In addition, Mr.
Roberts had concerns about breastfeeding and the effect it would have on his wife’s figure. He also perceived
breastfeeding as imposing severe limitations on his wife’s ability to be away from the baby for any length of time.

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Mrs. Roberts had little support or encouragement from family members in her efforts to breastfeed. Under the
circumstances, even the best information about breastfeeding was bound to be less than effective in helping her
attain her goal. The family’s influence might have been identified earlier and Mr. Roberts might have been
included in more of the patient teaching, which might have addressed many of his fears. The nurse, knowing the
attitudes of the couple’s mothers, might also have provided more individual support and suggestions to Mrs.
Roberts. Not surprisingly, the family’s attitudes and support, or lack thereof, have a far greater impact on the
degree to which patients follow health advice than mere information presented by a health professional. These
influences must be considered if teaching is to be used effectively to help patients follow recommendations.

The family may also influence the patient’s beliefs about the severity of various illnesses and the benefits
and costs of treatment. If family members fail to realize why a certain medicine is ordered to treat a specific
disease, or fail to see the cure or effects they had expected of treatment, their attitudes may be a direct barrier to
patient adherence.

FAMILY AND ILLNESS
Illness disrupts the family. Each individual within a family—whether child or parent—plays a certain role that the
family incorporates within its basic everyday function. When a family member becomes ill, other members must
also alter their lifestyle and make some allowances for role changes for the individual who is ill, as well as
changes in their own functioning. The illness of an individual within a family may cause all other members to
experience some degree of strain, whether the illness is acute or chronic. A child who is ill with otitis media and
is up most of the night, or who must stay home from school, requires parents and perhaps even other children to
reorganize some of their regular activities. If a husband who is the breadwinner suffers a myocardial infarction,
his wife may have to return to work to supplement, or bring in, income for the family. A grown child whose aging
parent becomes chronically ill may need to alter daily living patterns to accommodate care of the parent.

The extent of disruption of a family, of course, is dependent to some extent on the seriousness of the illness.
It is also dependent on the family’s level of functioning before the illness, on socioeconomic considerations, on
the emotional dependency of others, and on the extent to which the role of the person who is ill can be absorbed
by other family members. The dynamics of the family or other close personal relationships that existed before
illness affect family relationships after illness (Badr & Acitelli, 2005; Palmer & Glass, 2003; Pierce & Lutz, 2009).
In some instances, major illness brings a family closer together; in others, even a minor illness causes
significant strain. When conducting patient teaching, health professionals should assess the impact of illness on
the family because the group’s reaction can have a significant influence on the patient’s motivation to recover
and cooperate with the recommended treatment.

As previously mentioned, health professionals can gain this type of information by talking with, listening to,
and observing the patient and family and then altering teaching accordingly. Take, for example, the health
professional teaching the wife of a patient with a recent amputation about stump care. The health professional
may note the wife’s reluctance to look at the stump or touch it. The professional may also notice the wife
grimacing when procedures in stump care are discussed. At this point, an alteration in patient teaching may be
needed. The health professional may need to take time to talk privately to the wife about her feelings. If the
wife’s feelings cannot be altered, then the health professional may have to develop alternative methods to help
the patient with stump care at home. In any case, the health professional should be aware that the wife’s attitude
can affect the degree to which the patient is willing to follow recommendations.

In this context, it is important for health professionals to identify the meaning of the illness not only to the
patient but also to the family. The family’s perception of illness is often more important than the type of illness
for which the patient is being treated. The following two cases illustrate this point.

Michael was a 4-year-old boy with asthma and many allergies. Although Michael’s mother brought him to the
health clinic when he had asthma attacks and had received patient teaching about how to clear the home of
many of the allergens thought to precipitate his attacks, and about what to do to lessen their severity, Michael
continued to have frequent attacks. During one visit, the physician began to question Michael’s mother about the
changes she had made in the home to help reduce allergens in the environment. Many of the recommendations
had not been followed for a variety of reasons, none of which seemed substantial to the physician. Michael’s
mother concluded by saying, “Well, if I wasn’t working, I’d have time to do all the things I need to do. Our child’s
health is suffering because my husband insists I supplement our income. I never wanted to work outside the
home. Now we’re seeing what the consequences are.”

The physician gained some insight into the meaning of Michael’s asthma attacks. The boy’s attacks provided
his mother with an excuse to stay home as well as leverage to quit her job. Although her feelings were no doubt
unconscious, they appeared to be a strong contributing factor in Michael’s continued illness through lack of
adherence with the recommendations provided. Through identifying the meaning of Michael’s illness to his

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mother, the physician was able to take a different approach to patient teaching and to begin to help Michael’s
parents start to discuss openly some of the issues that were interfering with their son’s treatment.

In a second case, Mr. Arnett, a 65-year-old retired businessman with arteriosclerosis, had had a mild stroke
with some residual paralysis. Both Mr. and Mrs. Arnett received extensive teaching about his care and
rehabilitation, ways to prevent complications, and information about arteriosclerosis itself. Upon follow-up visits,
the nurse noted that although Mr. Arnett appeared to be progressing well physically and his degree of adherence
with recommendations appeared excellent, he seemed somewhat sad and withdrawn. Observation of the
interaction between Mr. and Mrs. Arnett alerted the nurse to the possibility that their relationship had become
somewhat strained. Further investigation indicated that Mrs. Arnett demanded that her husband comply rigidly
with every recommendation and enforced many of them quite literally, to the point where Mr. Arnett had very little
freedom to live his life to its full potential. After talking with the couple in several consecutive visits, the nurse
learned that Mrs. Arnett felt that Mr. Arnett’s illness was a great threat to his life. She feared being left alone and
became so frightened at the possibility that she had virtually made him a prisoner of health advice. After Mrs.
Arnett’s beliefs were revealed, the nurse was able to help her establish priorities in carrying out the teaching
recommendations, demonstrating which were crucial and where there could be more flexibility.

In other instances, illness may place individuals in a new family role that they prefer over the old role. For
example, a patient who has craved dependence and attention in the family, rather than functioning in an
independent role, may have less incentive to get well. On the other hand, if the illness of a dominant person
within the family enables another family member to assume the more authoritative role they desired, there may
be less support and encouragement to help the patient become well.

THE FAMILY MEMBER AS CAREGIVER
When the patient experiences a chronic illness or one that requires extended care, family members may need to
assume the role of primary caregiver. In some instances, family members accept this role out of love. In other
instances, it is out of a sense of duty or obligation. The individual’s primary motivation for assuming the role of
caretaker will affect his or her approach to the role of caregiver as well as his or her receptiveness to patient
teaching. Family members who assume the role of primary caregiver face multiple problems, issues, and
concerns. Although providing the role of caregiver can have many positive aspects, including a sense of
enrichment, pride, and a strengthened relationship between caregiver and patient, it can also have negative
aspects such as stress, strain, burden, and burnout.

When a family member becomes the primary caregiver, the health professional has an important role in
extending patient teaching to include the caregiver, and to assess his or her feelings and adjustments to the role.
By being alert to the effects of caregiving on the individual, the health professional can offer support and
reassurance if the impact of the role is perceived positively, or teaching and support about techniques or
resources for coping with stress or avoiding burnout if the impact is perceived negatively. Caregiving has been
associated with depression (Chumbler et al., 2004; Family Caregiver Alliance, 2006) as well as a variety of other
health problems (Halm & Bakas, 2007; Mausbach et al., 2007; Plowfield, Raymond, & Blevins, 2000). In addition to
teaching the family member who is acting as caregiver about the patient’s condition and treatment
recommendations, the health professional can also include patient teaching that will …

1688767 – Jones & Bartlett Learning ©

After talking with the couple in several consecutive visits, the nurse learned that Mrs. Arnett felt that Mr.
Arnett’s illness was a great threat to his life. She feared being left alone and became so frightened at the
possibility that she had virtually made him a prisoner of health advice. After Mrs. Arnett’s beliefs were revealed,
the nurse was able to help her establish priorities in carrying out the teaching recommendations, demonstrating
which were crucial and where there could be more flexibility.

In other instances, illness may place individuals in a new family role that they prefer over the old role. For
example, a patient who has craved dependence and attention in the family, rather than functioning in an
independent role, may have less incentive to get well. On the other hand, if the illness of a dominant person
within the family enables another family member to assume the more authoritative role they desired, there may
be less support and encouragement to help the patient become well.

THE FAMILY MEMBER AS CAREGIVER
When the patient experiences a chronic illness or one that requires extended care, family members may need to
assume the role of primary caregiver. In some instances, family members accept this role out of love. In other
instances, it is out of a sense of duty or obligation. The individual’s primary motivation for assuming the role of
caretaker will affect his or her approach to the role of caregiver as well as his or her receptiveness to patient
teaching. Family members who assume the role of primary caregiver face multiple problems, issues, and
concerns. Although providing the role of caregiver can have many positive aspects, including a sense of
enrichment, pride, and a strengthened relationship between caregiver and patient, it can also have negative
aspects such as stress, strain, burden, and burnout.

When a family member becomes the primary caregiver, the health professional has an important role in
extending patient teaching to include the caregiver, and to assess his or her feelings and adjustments to the role.
By being alert to the effects of caregiving on the individual, the health professional can offer support and
reassurance if the impact of the role is perceived positively, or teaching and support about techniques or
resources for coping with stress or avoiding burnout if the impact is perceived negatively. Caregiving has been
associated with depression (Chumbler et al., 2004; Family Caregiver Alliance, 2006) as well as a variety of other
health problems (Halm & Bakas, 2007; Mausbach et al., 2007; Plowfield, Raymond, & Blevins, 2000). In addition to
teaching the family member who is acting as caregiver about the patient’s condition and treatment
recommendations, the health professional can also include patient teaching that will help the caregiver maintain
his or her own health.

Although not all family members providing care experience stress, many do (Pierce & Lutz, 2009). The degree
of strain experienced depends on the type and intensity of care needed, the personal characteristics of the
caregiver, the amount of support available to the caregiver, the relationship between the patient and family
member, financial burden, and competing obligations the family member may be experiencing. Caregivers who
have a higher sense of self-efficacy and sense of personal mastery have been shown to experience fewer
untoward effects (Chumbler, Rittman, & Wu, 2008; Mausbach et al., 2007). Consequently, patient teaching with
the family member acting as caregiver helps him or her gain the knowledge and skills required to carry out
recommendations. It also offers support and reassurance and can help improve health outcomes not only for the
caregiver, but for the patient as well.

THE HEALTH PROFESSIONAL AND THE FAMILY
Family members cope with and adjust to the patient’s illness in different ways, depending on a variety of factors.
Family members have different knowledge levels, different emotional states, and different concerns. Patient
teaching efforts will be more successful if health professionals are able to recognize the impact that illness has
on the family and take steps to incorporate and individualize this information as they include the family in patient
teaching. By considering the needs and circumstances of family members when conducting patient teaching,
the health professional can begin to enlist the family as a system of support to help the patient adhere to
recommendations and achieve his or her health goals (Berry, 2007).

Gathering information about family structure, reactions, and interactions does not have to be time-
consuming. Much information about the family can be gathered through simple observation. Who appears the
most concerned and interested in the patient? What types of interactions are observed among family members?
Who talks to whom and in what way? What is the family’s general lifestyle? What activities appear important to
them?

1688767 – Jones & Bartlett Learning ©

Health professionals should also be alert to family reactions to learning about the patient’s condition and
treatment. Do family members appear apprehensive about learning skills to be used in caring for the patient at
home? Is there virtually no response from family members in patient teaching interactions? What stresses are
present in the family? How has the family coped with stress in the past? How are they coping now?

When conducting patient teaching that includes the family, health professionals should identify conceptual
problems through appropriate data gathering. The meaning of the patient’s illness to the family may be assessed
by asking members what they consider to be the major problems. Health professionals should develop sensitivity
to reactions and behaviors associated with different areas of patient teaching by observing verbal and nonverbal
indications. Does the family appear responsive to patient teaching? Is there dominance of conversation by one
family member? Are there numerous disruptions of patient teaching from the family?

When including the family in patient teaching, health professionals should use open and factual terminology
and use a calm and supportive approach with no unwarranted optimism or pessimism. Various goals in patient
treatment should be discussed so the family, as well as the patient, knows what to expect. Although patient
responsibility for carrying out treatment recommendations should be clearly established, the importance of the
family’s supportive role should also be stressed. If the patient has a chronic illness, or requires ongoing medical
intervention, it should be noted that just as patient teaching and feedback should be ongoing, so should be
teaching with family members. Proficiency in self-care skills and illness management evolves over time.
Learning how to make recommendations fit into the patient’s daily life not only requires problem solving with the
patient, but input from family members as well (Dickson & Riegel, 2009).

If particular problems are uncovered, they should be discussed along with ways they might be solved or at
least alleviated. Families themselves can be helped to generate options. Family values should be accepted rather
than criticized. Family members should receive help in recognizing and expressing their own feelings. Only after
health professionals have identified feelings and problems within the family can help be given to the family in
working toward solutions. Is lack of family support a barrier to patient adherence? Can the lack of support be
changed through intervention? If not, can the health professional provide additional support or refer the patient to
other sources of support? Can the health professional help the family identify outside resources that will
increase the patient’s potential for following recommendations?

Health professionals should also be aware of the tendency of family members who are anxious and under
stress to misunderstand or misinterpret what they are told. It is not uncommon for people to distort information,
turning it into what they want to hear. Such occurrences can cause conflicts between the patient and the family
and can contribute to nonadherence. It is often helpful to assess family members’ understanding of what they
have been told so that any misinterpretation can be corrected early. Although information should be given in a
positive way, it is also important that health professionals help family members develop realistic expectations.
Giving the patient and the family written information to read at a later time and then having them return to discuss
it may be helpful.

Using a family approach to patient teaching in which the family is viewed as the unit of care can help health
professionals provide more effective patient teaching (Gotler et al., 2001). Getting to know the patient in the
context of his or her family can be important in helping the patient meet his or her health goals. Health
professionals facilitate the effectiveness of patient teaching by fostering discussion among family members. If
health professionals have continued contact with the patient and the family, they may check on the patient’s
progress with the recommendations and identify any new problems or strains that interfere with adherence. This
helps the patient and his or her family find new solutions and resources to maximize the potential for compliance.

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Chumbler, N. R., Rittman, M. R., Van Puymbroeck, M., Vogel, W. B., & Qin, H. (2004). The sense of coherence, burden, and depressive symptoms in

informal caregivers during the first month after stroke. International Journal of Geriatric Psychiatry, 19(10), 944–953.
Chumbler, N. R., Rittman, M. R., & Wu, S. S. (2008). Associations of sense of coherence and depression in caregivers of stroke survivors across 2

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