Teaching Barriers and Learning Obstacles
Barriers to Teaching and Obstacles to Learning
It has been said by many educators that adult learning takes place not by the teacher initiating and motivating the learning process but rather by the teacher removing or reducing obstacles to learning and enhancing the process after it has begun. The educator should not limit learning to the information that is intended but should clearly make possible the potential for informal, unintended learning that can occur each day with every teacher-learner encounter (Carpenter & Bell, 2002; Gregor, 2001).
The evidence supports that these teachable moments are not necessarily unplanned or that a coordinated set of circumstances will always lead to positive health change. Instead, it is the interaction between learner and teacher that is central to the development of a teachable moment, regardless of the obstacles or barriers that may be encountered (Konradsen, Nielson, Larsen, & Hansen, 2012; Lawson & Flocke, 2009).
Unfortunately, nurses must confront many barriers in carrying out their responsibilities for educating others. Also, learners face a variety of potential obstacles that can interfere with their learning. Conditional factors, such as the environment, the organization's culture, the level of cooperation between the disciplines, beliefs and knowledge of the team members, types of patient education activities, and the patient population can either enable or hinder the teaching learning process (Farahani , Mohammadi, Ahmadi, & Mohammadi , 2013; Friberg et al., 2012).
For the purposes of this text, barriers to teaching are defined as those factors that impede the nurse's ability to deliver educational services. Obstacles to learning are defined as those factors that negatively affect the ability of the learner to pay attention to and process information.
Nursing Education and Factors Affecting the Ability
The following barriers (FIGURE 1-2) may interfere with the ability of nurses to carry out their roles as educators (Carpenter & Bell, 2002; Casey, 1995; Chachkes & Christ, 1996; Donovan & Ward, 2001; Duffy, 1998; Farahani et al., 2013; Friberg et al., 2012; Glanville, 2000, Honan. Krsnak , Petersen, & Torkelson, 1988; Smith & Zsohar, 2013; Tobiano et al., 2015):
Insufficiency of Time and Time Management
Lack of time to teach is cited by nurses as the greatest barrier to being able to carry out their educator role effectively. Early discharge from inpatient and outpatient settings often results in nurses and clients having fleeting contact with each other. In addition, the schedules and responsibilities of nurses are very demanding. Finding time to allocate to teaching is challenging very in light of other work demands and expectations.
In one survey by TJC, 28% of nurses claimed that they were not able to provide patients and their families with the necessary instruction because of lack of time during their shifts at work (Stolberg, 2002). Nurses must know how to adopt an abbreviated, efficient, and effective approach to client and staff education first by adequately assessing the learner and then by using appropriate teaching methods and instructional tools at their disposal. Discharge planning is playing an ever more important role in ensuring continuity of care across settings.
Lack of Competencies and Confidence
Many nurses and other healthcare personnel admit that they do not feel competent or confident with their teaching skills. As stated previously, although nurses are expected to teach, few have ever taken a specific course on the principles of teaching and learning. The concepts of patient education are often integrated throughout nursing curricula rather than being offered as a specific course of study. Pohl (1965) compiled some interesting statistics regarding nursing, long considered one of the first health professions to have a strong teaching role.
As early as the mid-1960s, Pohl (1965) found that one third of 1,500 nurses, when questioned, reported that they had no preparation for the teaching they were doing, whereas only one fifth felt they had adequate preparation. Almost 30 years later, Kruger (1991) surveyed 1,230 nurses in staff, administrative, and educational positions regarding their perceptions of the extent of nurses' responsibility for and level of achievement of patient education.
Although all three groups strongly believed that client and staff education is a primary responsibility of nurses, a large majority of respondents rated their ability to perform educator role activities as unsatisfactory. Many of the other health professions share similar views. Few new additional studies have been forthcoming on nurses' perceptions of their patient education and nursing staff/ student clinical teaching roles (Kelo, Martikainen, & Eriksson, 2013; Lahl, Modic, & Siedlecki, 2013; Nyoni & Barriers to Teat Barnard, 2016) .
Today, the role of the nurse as educator still needs to be strengthened in undergraduate nursing education. Fortunately, an upswing in interest and attention to the educator role has been gaining significant momentum in graduate nursing programs across the country.
Natural Personality Characters
Personal characteristics of the nurse educator play an important role in determining the outcome of a teaching-learning interaction. Motivation to teach and skill in teaching are prime factors in determining the success of any educational endeavor.
Low Priority for Education
Until recently, administrators and supervisory personnel assigned a low priority to patient and staff education. With the strong emphasis of TJC mandates, the level of attention paid to the educational needs of both consumers and healthcare personnel has changed significantly. However, budget allocations for educational programs remain tight and can interfere with the adoption of innovative and time-saving teaching strategies and techniques.
Environmental Factors
The environment in the various settings where nurses are expected to teach is not always conductive to carrying out the teaching learning process. Lack of space, lack of privacy, noise, and frequent interruptions caused by patient treatment schedules and staff work demands are just some of the factors that may negatively affect the nurse's ability to concentrate and effectively interact with learners. An absence of third party reimbursement to support patient education by RNs relegates teaching and learning to less than high-priority status.
Nursing services within inpatient healthcare facilities are subsumed under hospital room costs and, therefore, are not specifically nor separately reimbursed by insurance payers. In fact, patient education in some settings, such as home care, often cannot be incorporated as a legitimate aspect of routine nursing care delivery unless specifically ordered by a physician.
Financial Factors
Insurance coverage for healthcare services has historically been structured on a model of care with the physician as the primary provider being reimbursed on a fee-for-service basis. However, as of January 1, 2013, a new Medicare rule allows for payment of advanced practice registered nurses (APRNs) for the delivery of primary care services in outpatient settings. “With up to 20% of Medicare patients readmitted to hospitals within 30 days of discharge, more value has been placed on effective transitional care and care coordination” by APRNs (Nurse. com, 2012, para. 3).
Now a separate billing code for patient education and counseling by RNs is included in the American Medical Association's Common Procedural Terminology (CPT) codes, but many restrictions exist in being able to use this code for reimbursement of staff nursing services.
According to the sexually disease (STD) related Reproductive Health Training and Technical Assistance Center (STD TAC), this code cannot be used for new patients being seen by the nurse, for nursing transmitted services provided to the patient on the same day prior to or after a visit with a physician, or for telephone counseling for follow up teaching because the RN-patient encounter must be face to face (STD TAC, 2014).
As for health education and wellness programs, Medicare generally does not cover these costs except in specific cases, such as diabetes and kidney disease education, nutritional therapy for diabetes or kidney disease, obesity counseling, depression screenings, and counseling to stop smoking or for alcohol misuse (US Centers for Medicare & Medicaid Services, n.d.). Thus, under most circumstances when nurses deliver patient education, this therapeutic intervention is not reimbursable by third party payers.
Recently, a new role has been created in primary care practices, known as health education specialists (HES). HESS are trained to teach individuals and populations to practice healthy behaviors and seek preventive care, which nurses have traditionally performed. But given the nursing shortage in primary care settings and the cost of nursing professionals, HESS are being hired as substitutes to deliver patient education and coaching (Chambliss, Lineberry, Evans, & Bibeau, 2014).
Patient Education
Some nurses and physicians question whether patient education is effective in improving health outcomes. They view patients as impediments to teaching when patients do not display an interest in changing behavior, when they demonstrate an unwillingness to learn, or when their ability to learn is in question. Concerns about coercion and violation of free choice, based on the belief that patients have a right to choose and that they cannot be forced to comply, explain why some professionals feel frustrated in their efforts to teach.
Unless all healthcare members buy into the utility of patient education (that is, they believe it can lead to significant behavioral changes and increased compliance to therapeutic regimens), some professionals may continue to feel absolved of their responsibility to provide adequate and appropriate patient education.
Documentation Systems
The type of documentation system used by healthcare agencies has an impact on the quality and quantity of patient teaching. Both formal and informal teaching are often done but not written down because of insufficient time, inattention to detail, and inadequate forms on which to record the extent of teaching activities.
Many of the hard-copy forms or computer software used for documentation of teaching are designed to simply check off the areas addressed rather than allowing for elaboration of what has been accomplished. In addition, most nurses do not recognize the scope and depth of teaching that they perform daily. Communication among healthcare providers regarding what has been taught needs to be coordinated and appropriately delegated so that teaching can proceed in a timely, smooth, organized, and thorough fashion.
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