Patient Education

The process of patient education

There are several steps involved in effectively teaching patients, family members and staff about PICC line care and maintenance. The involvement of patients and family members in the process of patient education is promoted within the Joint Commission’s standard for patient education. According to the Joint Commission:

The instructor needs to assess the patient’s learning needs
The educational methods and instruction need to match the patient’s level of understanding and assessed needs.
The learning assessment should include cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations and barriers to communication.
Basic health and safety information including fall risks, medications, and equipment.
Evaluate the patient's understanding of the education and training.
Instructions for self-care upon discharge.

Adapted from The Joint Commission Comprehensive Accreditation and Certification Manual https://e-dition.jcrinc.com/Frame.aspx.

Assessment of the learning needs In Mager’s book (1997), Analyzing Performance Problems: Or, You Really Oughta Wanna--How to Figure out Why People Aren't Doing What They Should Be, he describes three issues that can lead to nonadherence to a prescribed plan of action: knowledge problems, system problems or compliance problems. In order for individuals to successfully adopt a positive mode of action they must

Know what to do
Be in a system that supports the action and
Be motivated by the benefits of the new behavior.

Applied to PICC line education

Assessing knowledge of risks of developing a PICC line infection

To know where a knowledge deficit exists, it is important to assess which factors pertain to a specific learner. There are different approaches to carrying out this assessment. It is possible to leave a questionnaire given to the patient and/or family member or staff member. A good resource is the Stanford Patient Education Research Center. They have numerous questionnaires available free online. http://patienteducation.stanford.edu/research/.

Assessing systems and adherence issues

We all live within various systems including our families, work and social systems. As the instructor before writing learning outcomes with the patient and family, it is also important to assess systems and adherence issues that might interfere with accomplishing preventative measures.

Ask the learner if there is anything blocking them from addressing any of the risk factors. For example, the learner may know the frequency of dressing change, cap change and flushing. However, lack of dexterity due to arthritis may make it difficult to carry out the procedure. That is an adherence problem.

Developing goals and objectives

To develop an active learning program the patient and/or family should be involved in developing objectives. Blooms taxonomy is often used to develop these objectives. (For more information go to http://www.nwlink.com/~donclark/hrd/bloom.html.) The learning objectives should reflect the time these risks will be addressed and by whom.

Sample learner outcomes:

Upon completion of these instructions, the learner will be able to

Demonstrate proper dressing change, flushing technique, and cap change.

Describe the frequency of dressing change, cap change and flushing.

List signs of catheter leakage and infections at site.

Describe 4 signs of catheter problems and when to call the home health nurse or physician's office.

Once these outcomes are agreed upon, a plan of instruction can be developed.

The patient or caregiver can be taught the procedure for maintaining the PICC line. The following is a sample care plan and visit schedule for home care of a patient with a PICC line. The visit frequencies were determined by a random, informal survey of home health care nurses who use PICC lines in their practice. The frequencies may need to be altered based upon the needs of the patient and caregiver.

Sample Home Health Care Plan for PICC Care (without home infusion)

Home Visit #

Assessment

Intervention

Evaluation

(Week 1) - 3 home visits

Visit #1

Full admission assessment if not previously completed.
Assess insertion site, note any leakage from catheter or around the site. Note any redness, drainage or pain at the site. Document condition of site and dressing.
Assess patient/caregiver knowledge gaps, i.e. safety, anatomy, handwashing, drsg and catheter protection, infection prevention, DVT prevention, normal limb use, lifting restrictions, adequate hydration,
etc.

Teach patient and /or caregiver to examine site to recognize normal appearance and warning signs of catheter problems i.e. catheter leakage, site infection, catheter occlusion when to call the home health nurse or physician's office.

Teach patient importance of catheter safety, emergency clamping, hygiene, handwashing, gloving and disinfecting, cleaning, drsg change, cap change and flushing.

Demonstrate proper port disinfection, flushing technique and cap change.

Demonstrate sterile dressing change i.e. positioning, masking, handwashing, working surface, opening sterile supplies, gloving (sterile techinque), etc.

Provide patient and /or caregiver with teaching material compatible with their learning preference: written, video etc.

Patient and/or caregiver verbally demonstrate understanding of the care and maintenance of the PICC
Patient and/or caregiver demonstrates procedural knowledge and performance capacity prior to intiating supervised catheter self-care, i.e. collecting necessary supplies for flushing, cleaning, drsg change.

Visit #2

Assess PICC line site, line note any leakage from catheter or around the site. Note any redness, drainage or pain at the site.

Document condition of site and dressing.

Assess patient's retention of previous teaching.

Reinforce prior teaching. If PICC dressing needs to be changed, allow patient/caregiver to return demonstrate if comfortable with this. If not, demonstrate dressing change and routine line care.

Patient will demonstrate proper flushing techniques

Or

Patient will verbally demonstrate procedural knowledge.

Visit #3

Assess PICC line site, line note any leakage from catheter or around the site. Note any redness, drainage or pain at the site.

Document condition of site and dressing.

Assess patient's retention of previous teaching.

Verbally repeat steps of PICC dressing change, cap placement and flushing.

Allow patient and /or caregiver to demonstrate the above.

Patient will accurately demonstrate PICC dressing change, cap change and flushing.

Patient will verbally demonstrate understanding of procedures to follow if a PICC line problem occurs.

Patient will verbally demonstrate understanding of criteria for calling home health nurse or physician for problems.

(Week 2) Visit #4

Discharge if appropriate.

Assess PICC line site, line note any leakage from catheter or around the site. Note any redness, drainage or pain at the site.

Document condition of site and dressing.

Assess patient's retention of previous teaching.

Allow patient and /or caregiver to demonstrate PICC care, cap change and dressing change.

Provide patient/caregiver with supplemental PICC care learning materials.

Patient will accurately demonstrate PICC dressing change, cap change and flushing.

Patient will verbally demonstrate understanding of procedures to follow if a PICC line problem occurs.

Patient will verbally demonstrate understanding of criteria for calling home health nurse or physician for problems.

Please visit the CDC resource again, and look under "Strategies for Prevention of Catheter-Related Infections in Adult and Pediatric Patients" (Quality Assurance and Continuing Education paragraph) https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

Learner concerns

General open-ended questions can be asked with opportunity to delve deeper into the answers.

What concerns do you have?
How do you prefer to receive information: hearing someone explain information, reading information or hands on learning?

We in health care are enthusiastic about individuals carrying out instructions that provide better health. Patients need to make their own goals and describe the benefits they see in changing. Patients and family members sometimes see a down side to what will be changing in their lives. This perception can create a block to changing behavior.

Assessing learning styles

It is important also to determine the patients learning style for effective teaching. One of the simplest yet effective tool is the VAK (Visual, auditory, kinesthetic) learning style from the field of neurolinguistics. In this tool individuals are visual, auditory or kinesthetic learners. Visual learners learn by reading, watching, or writing. Auditory learners listen, ask for information, like to discuss situations, talk on the phone. Kinesthetic learners, learn through touching, demonstrating, handling objects. Most individuals have a primary style in which they learn the best. Here is a website where you can access a VAK test to determine your style. https://www.businessballs.com/self-awareness/vak-learning-styles/.

Reading levels of patient materials

The American Medical Association (AMA) and the National Institutes of Health (NIH) recommend patient education materials to not be higher than a sixth-grade reading level (Weiss et al., 2005). Several studies have shown patient education materials used in health care organizations and online are written at a much higher level, presenting a deterrent to the comprehension of important information. Most word processing systems have a readability analysis in their system. The most popular and well-validated is the Flesch-Kincaid formula to analyze grade level readability. When using Word, the spell check must be completed first than the statistics on the area being typed, including the Flesch-Kincaid reading level, will come up. This section of the course, for example, has a 10.5 reading level – junior year in high school.

Carrying out the teaching

How teaching is carried out will vary based on the learners learning style and time available to do the education. Usually any instruction is limited to 30 minutes. Patients can listen to instruction, watch videos, read handouts at convenient times. Hospitals should have instructional materials available. All instruction should be noted in the patient’s record. Some institutions provide education after the patient is discharged. Group instruction can be helpful to prevent isolation and to hear questions individuals may have but are reluctant to express.

Evaluation should be based on the objectives decided with the learner. For example, one objective for teaching PICC line care is for the learner to Demonstrate proper dressing change, flushing technique, and cap change. Evaluation would be to observe the learner doing proper dressing change, flushing technique and cap change. Criteria for evaluation of proper care need to be used to evaluate if the leaner is carrying out the procedure correctly.

Evaluation would be to observe the learner doing proper dressing change, flushing technique and cap change. Criteria for evaluation of proper care need to be used to evaluate if the leaner is carrying out the procedure correctly.

Instruction evaluation

There should also be an evaluation that the learner completes about the instruction that was given. Typically questions about the quality of instruction, relevance and presentation are asked in a paper and pencil form.

References

Mager, R. & Pipe, P. (1997). Analyzing Performance Problems: Or, You Really Oughta Wanna--How to Figure out Why People Aren't Doing What They Should Be, and What to do About It. Atlanta: Center for Effective Performance.

The Joint Commission Comprehensive Accreditation and Certification Manual https://e-dition.jcrinc.com/Frame.aspx

Weiss, B., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P., Mockbee, J., & Hale, F. A. (2005). Quick assessment of literacy in primary care: the newest vital sign. Annals of Family Medicine, 3, 514-522.

Instant Feedback:

The instructor needs to assess and address knowledge gaps as well as any learner capacity that may affect adherence to safe self-care.

Sample Home Health Care Plan for PICC Care (without home infusion)

Home Visit #

Assessment

Intervention

Evaluation

(Week 1) - 3 home visits

Visit #1

Full admission assessment if not previously completed.

Assess insertion site, note any leakage from catheter or around the site. Note any redness, drainage or pain at the site. Document condition of site and dressing.

Assess patient/caregiver knowledge gaps, i.e. safety, anatomy, handwashing, drsg and catheter protection, infection prevention, DVT prevention, normal limb use, lifting restrictions, adequate hydration, etc.

Teach patient and /or caregiver to examine site to recognize normal appearance and warning signs of catheter problems i.e. catheter leakage, site infection, catheter occlusion when to call the home health nurse or physician's office.

Teach patient importance of catheter safety, emergency clamping, hygiene, handwashing, gloving and disinfecting, cleaning, drsg change, cap change and flushing.

Demonstrate proper port disinfection, flushing technique and cap change.

Demonstrate sterile dressing change i.e. positioning, masking, handwashing, working surface, opening sterile supplies, gloving (sterile techinque), etc.

Provide patient and /or caregiver with teaching material compatible with their learning preference: written, video etc.

Patient and/or caregiver verbally demonstrate understanding of the care and maintenance of the PICC

Patient and/or caregiver demonstrates procedural knowledge and performance capacity prior to intiating supervised catheter self-care, i.e. collecting necessary supplies for flushing, cleaning, drsg change.

Visit #2

Assess PICC line site, line note any leakage from catheter or around the site. Note any redness, drainage or pain at the site.

Document condition of site and dressing.

Assess patient's retention of previous teaching.

Reinforce prior teaching. If PICC dressing needs to be changed, allow patient/caregiver to return demonstrate if comfortable with this. If not, demonstrate dressing change and routine line care.

Patient will demonstrate proper flushing techniques

Or

Patient will verbally demonstrate procedural knowledge.

Visit #3

Assess PICC line site, line note any leakage from catheter or around the site. Note any redness, drainage or pain at the site.

Document condition of site and dressing.

Assess patient's retention of previous teaching.

Verbally repeat steps of PICC dressing change, cap placement and flushing.

Allow patient and /or caregiver to demonstrate the above.

Patient will accurately demonstrate PICC dressing change, cap change and flushing.

Patient will verbally demonstrate understanding of procedures to follow if a PICC line problem occurs.

Patient will verbally demonstrate understanding of criteria for calling home health nurse or physician for problems.

(Week 2) Visit #4

Discharge if appropriate.

Assess PICC line site, line note any leakage from catheter or around the site. Note any redness, drainage or pain at the site.

Document condition of site and dressing.

Assess patient's retention of previous teaching.

Allow patient and /or caregiver to demonstrate PICC care, cap change and dressing change.

Provide patient/caregiver with supplemental PICC care learning materials.

Patient will accurately demonstrate PICC dressing change, cap change and flushing.

Patient will verbally demonstrate understanding of procedures to follow if a PICC line problem occurs.

Patient will verbally demonstrate understanding of criteria for calling home health nurse or physician for problems.

Assess patient/caregiver knowledge gaps, i.e. safety, anatomy, handwashing, drsg and catheter protection, infection prevention, DVT prevention, normal limb use, lifting restrictions, adequate hydration,
etc.