Auditory and Visual Impairment In Patient and Nursing Education
What Is Visual Impairments
Approximately 285 million people worldwide are visually impaired. Of this total, 39 million are blind, and 246 million have low vision (WHO, 2015a). Findings from the 2015 National Health Interview Survey (NHIS) indicate that the number of adults in the United States with some degree of vision impairment has grown to 23.7 million people or about 10% of the adult population.
Over one half million children in the United States are classified as legally blind (American Foundation for the Blind, 2017b). These survey data further indicate that vision loss is more common among women, older adults, and people who are poor or near poor.
Blindness and visual impairment are caused by many factors (FIGURE 9-1). Disease is the major cause of loss of vision in adults, with cataracts, age-related macular degeneration, glaucoma, and diabetic retinopathy accounting for the greatest number of disease-related impairments (Braille Institute, 2016; Lighthouse International, 2015; National Institutes of Health, 2017).
Although vitamin A deficiency is the leading cause of blindness in children worldwide, amblyopia and strabismus, optic nerve neuropathy, prematurity, low birth weight, and congenital conditions such as congenital cataracts are the most common factors leading to blindness in children in the United States ( International Agency for the Prevention of Blindness, 2017).
Although severe vision loss provides the greatest challenge to the nurse as educator, it is important to note that mild to moderate vision loss is commonplace. The most prevalent conditions that result in some degree of visual impairment are myopia (nearsightedness), hyperopia (farsightedness), astigmatism (distorted vision at all distances), and presbyopia (loss of ability to focus up close for reading), the latter of which occurs in middle aged adults (CDC, 2015c).
These refractive errors usually can be corrected with eyeglasses or contact lenses. Correction of common visual impairments has implications for safety and quality of life by reducing falls, fractures, depression, and car accidents (Welp, Woodbury, McCoy, & Teutsch, 2016).
A visual impairment is defined as some form and degree of visual difficulty and includes a wide spectrum of deficits, ranging from partial vision loss to total blindness; it may also include visual field limitations, such as tunnel vision, alternating areas of total blindness and vision, and color blindness.
In the United States, a person is determined to be legally blind if vision is 20/200 or less in the better eye with correction or if visual field limits in both eyes are within 20 degrees in diameter.
Approximately 90% of people who are legally blind have some degree of vision. Typically, a person who is legally blind is unable to read the largest letter on the eye chart with corrective lenses (American Foundation for the Blind, 2017b). In comparison, total blindness is defined as an inability to perceive any light or movement (American Foundation for the Blind, 2017a).
Fortunately, many devices are available to help legally blind persons maximize their remaining vision. People who are without sight most likely have had services and are familiar with those adaptations that work best for them.
However, depending on patients' situations and the circumstances under which the nurse is teaching, the nurse educator may want to further investigate their background to ensure that the most appropriate format and tools for communicating with visually impaired patients are being used.
Patients who seem to be legally blind but who have not been evaluated by a low vision specialist should be provided with contact information for these sources: the local blind association and the local commission for the blind and visually handicapped. Patients may require assistance in negotiating the complex system and in obtaining services.
Barriers Encountered in Nursing Education
Healthcare encounters present challenges for both the patient with low vision or blindness and for the professionals who care for them. In a series of focus groups with people with blindness or low vision, O'Day. Killeen, and lezonni (2004) identified four barriers encountered in healthcare settings:
Lack of respect
Communication problems
Physical barriers
Information barriers
Lack of respect was the basis for many of the negative healthcare encounters described by the participants. For example, participants felt that healthcare providers often made assumptions that patients would be unable to participate in their own care and recovery.
Subsequent studies supported this finding. In a study of barriers to low vision rehabilitation, Southhall and Wittich (2012) found that people with visual impairments were often reluctant to disclose their vision loss for fear of triggering prejudice and discrimination.
Directing comments to a sighted companion rather than to the patient was another common complaint. In terms of education, participants expressed concern that many health providers are not prepared to care for people with visual impairments. Without Braille versions of information sheets, audiotaped instructions, and other assistive strategies, patients with visual impairments left teaching sessions anxious and, most important, without the information required.
Steps to Improvements in Nursing Education
The following are some tips nurses might find helpful when teaching patients with visual impairments (Babcock & Miller, 1994; Boyd, Gleit, Graham, & Whitman, 1998; Luckowski & Luckowski, 2015; Manduchi & Coughlan, 2012 ; McConnell , 1996 ; University of Washington, 2012):
As a first step, assess patients to avoid making assumptions about their needs because a person who is blind may be very different from one who has low vision. Additionally, multiple disabilities must be considered, particularly when working with older adults.
Make sure to speak directly to patients rather than to their sighted companions.
Contact a low vision specialist who can prescribe optical devices such as a magnifying lens (with or without a light), a telescope, a closedcircuit TV, or a pair of sun shields, any of which will help nurses to adapt them teaching materials to meet the needs of their patients.
Rely on patients' other senses of hearing, taste, touch, and smell when conveying messages as a means to help them assimilate information from their environment. Because their listening skills are usually particularly acute, it is not necessary to shout. When teaching, the nurse should speak in a normal tone of voice.
Always approach patients by announcing your presence, identifying yourself and others, and explaining clearly why you are there and what you are doing because people who are blind cannot take advantage of nonverbal cues such as hand gestures, facial expressions, and other body language . Instead, use their talents of memory and recall to maximize learning.
If a handshake is appropriate, take the client's hand first. It is also important for the nurse to indicate when a conversation is over and when he or she is leaving the room.
When teaching psychomotor skills, describe as clearly as possible the steps of a procedure, explain any noises associated with treatments or the use of equipment, and allow patients to eleven touch, handle, and manipulate equipment so that they can perform return demonstrations. Use the tactile learning technique when. teaching them the characteristics and the placement of objects.
For example, allow patients to identify their medications by feeling the shape, size, and texture of tablets and capsules. To locate their various medicines, glue pills to the tops of bottle caps or put them in different sized or different shaped containers; keep items in the same place at all times so they can independently locate their belongings; and arrange things in front of them in a regular clockwise fashion to facilitate learning when performing a task that must be accomplished in an orderly step-by-step manner.
Enlarge the font size of letters in printed and handwritten materials as a typical important first step in using these types of instructional tools.
Use bold colors to provide contrast, which is a key factor in helping a person with limited sight distinguish objects. Assess whether black ink on white paper or white ink on black paper is better; if using a dark placemat with white dishes or serving black coffee in a white cup helps them to see items more clearly; and if placing pills, equipment, or other materials on a contrasting background helps them locate objects they need.
Use proper lighting, which is of utmost importance in assisting patients to read or locate objects. Regardless of the print size, the color of the type, or the paper used, if the light is not sufficient, patients will have a great deal of difficulty distinguishing words or manipulating objects.
Provide large print watches and clocks with either black or white backgrounds that are available through a local chapter for the visually handicapped.
Make use of audiotapes and cassette recorders as instructional tools to convey patient education, some of which are available as talking books and can be obtained through the National Library Service or through the state library for the blind and visually handicapped. Also, oral instructions can be audiotaped to be listened to as necessary at another time and place and can be played over again as many times as needed to reinforce learning.
Make use of standard computer features such as screen magnifiers (which can change the text to be 2 to 16 times larger than the normal view), high contrast (which can invert typical black-on-white to other color options) and screen- resolution adjustments (which make information on the computer screen easier to see). Advanced assistive technology comes equipped with text-to-speech converters; synthetic speech; screen readers; and Braille keyboards, displays, and printers.
Access appropriate resources for information, such as the Braille library, the National Braille Press, or local blind associations for printed educational materials.
When teaching ambulation, always use the sighted guiding technique by allowing the patient to grasp your forearm while walking about one half-step ahead of the blind person or seek the referral of a mobility specialist available through the local associations for the blind.
Hold teaching sessions in quiet, private spaces, whenever possible, to minimize dis tractions and to allow adequate time to deliver instruction in an unhurried manner.
Diabetes education consumes a great deal of a nurse educator's teaching time and presents unique challenges. Because of the high incidence of this disease in the US population, diabetic retinopathy is a major cause of blindness. Patients who have lost their sight because of this disease probably have already mastered some of the necessary skills to care for themselves but will need continued assistance.
Also, it is possible for persons with visual impairments to be diagnosed with diabetes at a later time in their life. In either case, these patients will need to learn how to use appropriate adaptive equipment.
Fortunately, there has been continuous improvement in the equipment used for self-monitoring of blood glucose levels and for self injection of insulin. Easy-to-use monitors with large display screens or voice instructions are now available as are new nonvisual adaptive devices for measuring insulin, insulin pens that contain prefilled dosages, and built-in magnifiers that have made insulin administration much easier for patients who have difficulty reading a syringe (Cohen & Ayello , 2005).
Learning Disabilities In Nursing Education
Learning disabilities have emerged as a major issue in the United States (CDC, 2015a). Although often associated with school-aged children, these neurologically based disorders begin in childhood and persist through adulthood (Taymans et al., 2009). Learning disorders are complex conditions that are frequently hidden and vary from individual to individual.
As a result, they are often misunderstood and under-estimated (Child Development Institute, 2012: Learning Disabilities Association of America. 2013; LD Online, 2017; National Joint Committee on Learning Disabilities, 2011; Santrock, 2017; Snowman & McCown, 2015 ).
A definitive definition of the term learning has been the subject of a great deal of controversy over the years as educators and psychologists alike have debated the issues (Crandell, Crandell, & Vander Zanden, 2012; Santrock, 2017; Snowman & McCown. 2015 ; Ysseldyke & Algozzine , 1983).
Resulting from this debate, many definitions of learning disabilities can be found in the literature, most of which can be categorized as either medically or educationally based (National Center for Learning Disabilities INCLD], 2017). The medical model definitions are based on the Diagnostic and Statistical Manual (DSM) of Mental Disorders and focus on the deficit present with each type of learning disability.
For example, the DSM-5 describes learning disabilities as a diagnosis requiring “persistent difficulties in reading, writing, arithmetic, or mathematical reasoning skills during formal years of schooling” (NCLD, 2014, p. 2).
Educationally based definitions of learning disabilities are derived from the federal education law, Individuals with Disabilities Education Act (IDEA), and emphasize the neurological processing disorder that underlies the condition.
The IDEA definition, which stands as the accepted working definition for purposes of assessment, diagnosis, and categorization of an array of learning disabilities, states that a learning disability is a “disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or do mathematical calculations” (NCLD, 2017, para. 4).
Learning disabilities is an umbrella term that is used to describe an array of conditions including dyslexia, dyscalculia, and auditory processing disorder.
Experts agree on some common characteristics of learning disabilities (Child Development Institute, 2012; LDOnline , 2017; National Joint Committee on Learning Disabilities, 2011), such as they: involve learning problems and uneven patterns of development in children and adults can be identified in childhood and yet continue to persist into adulthood.
For example, difficulty with language development in a preschool child may signal long-term learning challenges in the school-aged child that may go unresolved through the adult years. are neurobiologically based and are caused by factors other than environmental disadvantage, mental retardation, and emotional disturbance are the result of a different wiring of the human brain that influences the way in which information is received, processed, and communicated.
The causes of learning disabilities are varied and often unclear. Genetics plays a role in approximately 50% of cases. Also, it is suspected that numerous factors that affect the brain, especially during gestation, delivery, and the early years of life, can result in a learning disability.
For example, the use of alcohol during pregnancy, difficulties during delivery, and exposure to toxins such as lead paint can all result in learning disabilities (Learning Disabilities Association of America, 2015), learning sobering. Nearly 6% of the children in the US public school system have been identified as having a learning disability (National Center for Education Statistics, 2016).
The rate of learning disabilities in adults is probably similar to that in children. However, adults who were in school prior to the passage of federal special education legislation may never have been diagnosed, which therefore results in lower numbers of identified individuals.
Self reporting among the adult population reveals a rate of learning disabilities that ranges from .07% to 2.7% with younger adults more likely to report a learning disability than older adults (NCLD, 2014). Overall, approximately 4.6 million or 1.7% of Americans live with a learning disability (NCLD, 2014).
About three to four times as many boys as girls are identified as having a learning disability, but this gender difference is thought to result from referral bias more boys are sent for identification and treatment because of their behavior (Crandell et al., 2012 ; Santrock, 2017). Children with learning disabilities represent the largest segment of those in special education classes, accounting for nearly 40% of the group (Aron & Loprest , 2012).
Lifelong challenges extend far beyond the classroom for children and adults with learning disabilities and their families. A survey of parents found that higher levels of parental distress as well as higher levels of child anxiety and depression exist when a child has a learning disability ( Bonifacci , Storti, Tobia, & Suardi , 2016). Only one third of parents surveyed reported positive feelings about their children's abilities to learn and their own abilities to cope (NCLD, 2014).
Children with learning disabilities, like other children, are often victims of bullying. Approximately, 46% of parents of children with learning disabilities report that their child has been bullied (NCLD, 2014), a figure that is consistent with the rest of the child population (Bullying-statistics.org. 2017; Klomek et al . 2016 ; Rose, Espelage, Monda Amaya, Schogren , & Aragon, 2015).
Graduation rates for children with disabilities vary from state to state, but overall, they earn a high school diploma at a lower rate than other children ( Yettick & Lloyd, 2015). Approximately 27% of high school students with learning disabilities drop out of school, and only 14% of high school students with learning disabilities go on to postsecondary education programs (US Department of Education, 2006).
Among the adult population with learning disabilities, 46% are out of the workforce and approximately 92% have annual incomes of less than $50,000 within 8 years of leaving high school, with many living at the poverty level (Cortiella & Horowitz, 2014 ) . Estimates of the number of inmates and parolees with learning disabilities are as high as 65% (Learning Disabilities Association of America, 2015).
Although evidence-based research on adults with learning disabilities is limited, data suggest that although some adults with learning disabilities do poorly-and in fact, some report that the disability and associated challenges get worse over time many adults with learning disabilities overcome the associated challenges and lead happy, successful lives (Gerber, 2012).
Given this fact, it is important that the nurse does not make assumptions about the presence or absence of a learning disability based on an individual's employment or financial status. Despite the statistics that reveal the lifelong challenges of individuals with learning disabilities, many individuals with learning disabilities have been found to have at least average, if not superior (gifted), intelligence.
In fact, learning disabilities are often labeled “the invisible handicap” because they do not necessarily result in low achievement. Some very famous and successful people in world history are thought to have had some type of learning disability ranging from artists (Leonardo da Vinci) to political leaders (Woodrow Wilson, Winston Churchill, and Nelson Rockefeller) to military figures (George Patton) to scientists (Albert Einstein and Thomas Edison) (Crandell et al., 2012).
Even though a large discrepancy may be noted between the intellectual abilities of a person with a learning disability and his or her performance levels, no cause-and-effect relationship exists. Persons who exhibit this discrepancy are not necessarily learning disabled (Crandell et al., 2012; Santrock, 2017).
Although these problems and their associated characteristics are frequently identified when referring to children with disabilities, many of these characteristics and problems can apply equally as well to an older person who has not been diagnosed as learning disabled until later in adulthood. It is important to remember that an individual with a learning disability can experience one type of learning disability or a combination of various types of such disabilities.
Dyslexia is “a neuro-developmental learning disorder that is characterized by slow and in-accurate word recognition” despite conventional instruction, adequate intelligence, and intact sensory abilities (Peterson & Pennington, 2012, p. 1997). Dyslexia accounts for the largest percentage of people with learning disabilities, affecting approximately 10% to 15% of the US population (Crandell et al., 2012; Dyslexia Research Institute, 2017).
Often associated with reading difficulty, dyslexia is actually a language disorder that results in a wide array of symptoms, including difficulty sounding out words (decoding), word recognition, and/or reading comprehension (Handler, 2016). Individuals with dyslexia often have other learning disabilities, including attention-deficit/hyperactivity disorder, language impairment disorder, and speech sound disorder (Dyslexia Research Institute, 2017; Peterson & Pennington, 2012).
Dyslexia has been the subject of considerable research and although many questions remain, some significant discoveries related to this condition have been made in recent years. Current research findings suggest that dyslexia is moderately heritable; the cause is multifactorial with genetic and environmental risk factors (Handler, 2016; Peterson & Pennington, 2012).
Although the diagnosis of dyslexia is associated with several genes, factors such as parental education have been found to have the potential to modify genetic risk (Pennington, McGrath, Rosenberg, Barnard, & Smith, 2009). In addition, dyslexia are associated with early hearing loss, and it is suggested that this hearing loss results in a failure of the brain to make the necessary connections between sounds and letters.
It is a common misconception that people with dyslexia simply see letters in reverse order or upside down. In reality, dyslexia is much more complex. Recent research indicates several subtypes of dyslexia exist, each characterized by a different neurologic deficit (Handler, 2016; Heim et al., 2008; Menghini et al., 2010; Wajuhian & Naidoo, 2012 ) .
These subtypes are made up of a combination of problems including the inability to break down words into individual sounds. difficulty distinguishing letters visually, and an inability to associate sounds with letters (Heim et al., 2008; Hultquist, 2006; Public Broadcasting Service [PBS], 2010). Furthermore, people with dyslexia have been shown to have a deficit in “working” or “short term memory making it difficult for them to process complex sentences (Crandell et al., 2012; Wiseheart, Altmann, Park, & Lombardino, 2008) .
These deficits contribute to an overwhelming classroom experience for children or adults with dyslexia as they attempt to listen and write at the same time while being distracted by surrounding noise as they try to understand the content being presented (Olds. 2016). Levine (2002) has created a website, Misunderstood Minds, that includes exercises that simulate the reading difficulties of some-one with dyslexia (http://www.pbs.org/wghh/misunderstood minds).
Although people with dyslexia can learn to read, the challenges they face can result in self-esteem issues that often begin early in life (Olds, 2016). Young children often experience problems at school because of their disability (Ingesson, 2007), and older adults who were never diagnosed or who did not receive reading intervention are at greatest risk. The nurse must be sensitive to these issues when engaged in teaching.
People with visual perception problems such as dyslexia face many other challenges. For example, they may experience a figure-ground problem such that the person is unable to attend to a specific object within a group of objects, such as finding a cup of juice on a food tray.
Furthermore, judging distances or positions in space or dealing with spatial relationships may prove difficult, resulting in the person bumping into things, being confused about left and right or up and down, or being unable to throw a ball or do a puzzle.
Nurses face numbers of issues when teaching patients with dyslexia and other types of perceptual deficits. Assessment is a critical first step. A discussion with the patient is advisable to determine the extent of the individual's abilities and disabilities and how he or she learns best. For example, many people with visual perceptual deficits tend to be auditory learners. Those who learn best by hearing need to have visual stimulation kept to a minimum.
Visual materials such as pamphlets and books are ineffective unless the content is explained orally or the information is read aloud. If visual items are used, nurses should give only one item at a time, with a sufficient period in between times to allow for the patient to focus on and master the information. It may also be helpful to add pictures to written material wherever possible to help convey information. CDs and audiotapes (with or with out earphones) and verbal instruction may be beneficial as well.
Some patients with dyslexia have difficulty with the spoken word and may struggle to express themselves or understand what is being said to them (International Dyslexia Association, 2017). For these clients, it is important to proceed in an unhurried manner, presenting small amounts of information over time with frequent assessment of learning.
If a patient has difficulty with spoken as well as written words, a combined approach using both oral instruction and visual information may be effective. Nurses can assess recall and retention of information by oral questioning, allowing learners to express orally what they understand and remember about the content that has been presented.
Assistive technology is now available for use in the classroom or work environment that can enhance teaching learning situations for people with dyslexia. For example, smart pens can record information while they take notes, which allows them to listen again to what they were taught.
So, reading pens allow them. to scan information that can be enlarged or displayed with syllabic breakdown of words (Dyslexia Help, 2017). Finally, when teaching motor skills, it is important for nurses to remember that people with dyslexia may have impaired left-right discrimination and may become confused during instruction and coaching if the nurse makes reference to a “left hand” or “right foot .” “To help overcome this problem, nurses can tape an X on the appropriate hand or refer to the arm with the watch.”
Auditory Processing Disorder In Nursing Education
An auditory processing disorder (APD). also known as a central auditory processing disorder (CAPD), is an umbrella term used to describe a condition that causes listening difficulties despite normal or near normal hearing acuity (Bellis, 2017; de Wit et al., 2016). CAPD is the result of an inability of the central nervous system to efficiently process or interpret sound impulses (Kids Health, 2017).
Under usual conditions, sound vibrations are converted to electrical impulses in the ear and then transmitted by the auditory nerves to the brain, where they are interpreted. APDs occur when the brain fails to process or interpret these sound impulses effectively. This type of disability affects approximately 5% of children (Kids Health, 2017).
Because the central nervous system is complex, it is important to note that there are many reasons why an individual may not attend to, understand, and/or remember what he or she hears. CAPD should not be confused with other conditions such as attention-deficit/hyperactivity disorder that includes similar symptoms but is caused by a different underlying deficit (Bellis, 2017).
Although the cause of CAPD is usually unknown, this condition can be developmental or acquired and is associated with ear infections and head trauma in both adults and children (Musiek.
Barran, & Shinn, 2004). Educators as well as speech, language, and other professionals who work with individuals with APD have been engaged in debate about various aspects of the condition for many years (Richard, 2011). For example, there is no universally accepted definition of APD (Campbell, 2011).
Much of the controversy stems from a lack of understanding of the underlying mechanism involved. According to CA Miller (2011),We learn our native language by listening to speech. If the sounds of speech are not delivered to the language system accurately and quickly, then surely language ability will be compromised.
However, despite decades of research, a complete theoretical account of how auditory perceptual deficits lead to impaired language has proven elusive. In the absence of such an account, auditory processing has become a buzzword that has almost as many meanings as there are people who use it. (p. 309)
APD is characterized by the inability to distinguish subtle differences in sounds-for example, blue and blow or ball and bark. There may also be a problem with the auditory figure ground relationship, such that the sound of someone speaking cannot be identified clearly when others are speaking in the same room. Auditory lags may occur, whereby sound input cannot be processed at a normal rate.
Parts of conversations may be missed unless one speaks at a speed that allows the individual enough time to process the information.During instruction, it is important to limit the noise level and eliminate background distractions. Using as few words as possible and repeating them when necessary (using the same words to avoid confusion) are useful strategies.
Nurses should work with the patient to determine the volume and rate of speech that are best understood. For example, some patients find that speech that is a little slower and a little louder works well (Musiek et al., 2004). Direct eye contact helps keep the learner focused on the task at hand.
Visual teaching methods such as gaming (eg, puppetry), demonstration-return demonstration, role model, and role play, as well as providing visual instructional tools such as written materials, pictures, charts, films, books, puzzles. printed handouts, and the computer are the best ways to communicate information. Using hand signs for key words when giving verbal instructions and allowing the learner to have hands on experiences and opportunities for observation are helpful techniques.
Individuals with auditory processing problems often rely on tactile learning as well. They enjoy doing things with their hands, want to touch everything, prefer writing and drawing, engage in physical exploration, and enjoy physical movement through sports activities.
Individuals with APD may rely on vision to help them learn. The visual learner may intently watch the instructor' Dyscalculia can be either developmental (ie, acquired at birth) or the result of injury to the brain. The developmental form of this condition is present in 5% to 6% of school-aged children and persists for some individuals into adulthood (Wilson, 2012).
Developmental dyscalculia is suspected when a child fails to perform in mathematics at a level consistent with his or her chronological age and level of intelligence despite adequate instruction ( Dyscalcu lia.org, 2017). Acquired dyscalculia can occur at any time. Individuals with dyscalculia often have other learning or developmental disabilities such as dyslexia or attention-deficit/hyper-activity disorder (ADHD) (Rapin, 2016).
It is important for nurses to recognize that the impact of dyscalculia on a patient extends beyond his or her ability to calculate an insulin dose or count the correct number of pills. Such individuals may also have the following issues (Dyscalculia.org, 2017):
Difficulty grasping the abstract concept of time. As a result, these clients may be unable to read a clock, follow a schedule, or understand the sequence of past and future events. Inability to differentiate between right and left.
Problems In Learning Activities In Nursing Education
Problems with learning specific activities that require sequential processing that is, any activity in which steps must be followed.
Problems with reading numbers, such as on a prescription bottle.
Confusion when schedules/routines change.
The approach to working with a patient with dyscalculia varies depending on the age of the individual and his or her experience with this disorder. A teenager or adult who has lived with dyscalculia for many years may have developed strategies for addressing issues such as time, schedules, and numbers. It is important that assessment be done prior to teaching to determine the extent of the disability and the coping strategies that have been successful for the patient.
As with any person who has a learning, teaching should be done in a disability environment that is as free from distraction as much as possible and conducted in an unhurried man. Nurses may find it helpful to begin with the concrete when teaching and then move to the abstract slowly and carefully. Pictures and diagrams may help the patient grasp more abstract concepts. Assessment is vital to determine that the patient has learned the content or skills presented and reinforcement of learning is critical.
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