Self Care for Elderly Patients

Learner-Centered Instruction: Teaching Patients How to Care for Themselves When They Have a Diagnosis of Congestive Heart Failure
Part I
Introduction
Teaching patients how to care for themselves when they have a diagnosis of congestive heart failure has been shown to be “effective in improving self?care and reducing readmissions” (Stromberg, 2005). This project will provide a lesson plan that nurses can implement using a learner-centered instruction approach in order to help patients with congestive heart failure properly and effectively apply self-care.
Rationale
Currently there is a need for better self-care among patients with congestive heart failure, as shown by Dickson and Riegel (2009) and Harkness, Spaling, Currie, Strachan and Clark (2015), as self-care can help to empower patients to provide more effective relief and management of their own health. Moreover, Tsai, Wang, Lee, Tsai & Chen (2015) show that self-care can help reduce re-admission rates and prevent patients from misapplying treatments on their own. As congestive heart failure is responsible for “11 million physician visits each year, and more hospitalizations than all forms of cancer combined,” it is imperative that steps to help patients to better cope with this health issue be taken (Emory Healthcare, 2018). To achieve that aim, Tsai et al. (2015) conclude that “establishment of heart disease educators and professional consultation services may be helpful to improve patient education” (p. 1101). This present paper aims to provide a first step in assisting in that process by developing a lesson plan for heart disease educators.
From the patient’s point-of-view, it is important that they understand what they need to know and how to apply self-care effectively. Based on their assessment of patients with heart failure Dickson and Riegel (2009) showed that “skill-building tactics, such as role-playing in specific situations, are needed” when teaching patients with heart failure how to care for themselves. This type of approach can give patients a better sense of what to do, how to do it and when: role playing, especially, helps to give them a concrete example to go by rather than that which is provided by traditional teaching methods where information is simply relayed by the teacher and expected to be received passively by the patient. Role-playing facilitates active learning, which helps lessons to be more deeply understood by the learner (Jensen, 2005). Additionally, in their follow-up study to their earlier research, Riegel, Dickson and Faulkner (2016) show that situation-specific heart failure self care can help patients to identify their own symptoms and make better decisions for themselves. This situation-specific approach conforms with the findings of Harkness et al. (2015) who show that individualized care is essential for patients seeking to better care for themselves.
Setting
The setting for this project can be the hospital facility where congestive heart failure patients receive primary care from physicians and nurses and training in self-care from a health educator, or it can be in a non-hospital setting, such as a nursing home or the home wherein the patient lives, provided the nurse is able to make a home visit. As this project focuses on learner-centered instruction, the recommended setting is wherever the patient-learner is most comfortable so that care can be truly individualized. The audience for this project consists of the health educator who provides the self care instruction and the heart failure patient who receives the instruction.
The Learner
The learner in this case is the congestive heart failure patient. Approximately 6 million Americans are impacted by heart failure, which is the leading cause of hospitalization among the elderly population (people aged 65 and older). However, the demographic for congestive heart failure is wider than that: it actually affects people of all ages, from children to the elderly. Approximately 1.4 million individuals under the age of 60 have congestive heart failure, while 2% of individuals between the ages of 40 and 5 suffer from heart failure—though the percentage rises to 5% among persons between the ages of 60 and 69. Heart failure is just as frequent among men as it is among women, but African Americans are 1.5 times more at risk of developing heart failure than are Caucasians (Emory Healthcare, 2018). Since virtually anyone can be a learner for this type of self care, there are also various levels of education that they are likely to have—from elementary levels of education to middle school to high school to college to post-graduate levels. For the purposes of this project, the learners chosen will be from the most common demographic of elderly patients.
Learning Needs
Physical
The learners must be physically able to care for themselves, must have the “gross motor movements, sensory acuity, adequate strength, flexibility, coordination, and endurance” (Bastable, 2014, p. 126). The tasks must also be such that they are not too complex to be mastered and do not conflict with the learner’s environment. For elderly patients, instructors will have to allow “more time to react and respond to stimuli” (Bastable, 2014, p. 126). For the elderly population, these conditions must be present or else self care cannot be taught.
Emotional
As Bastable (2014) notes, learners must also be “emotionally ready to learn”—i.e., they must not be too anxious; they must have a secure and stable support system; they must be motivated; they must not be prone to taking risks; their frame of mind must be balanced, and their developmental stage should be advanced so that they are mature enough to take on the responsibility of self care (p. 127). The elderly learner must meet these emotional conditions or else self care cannot be taught.
Experiential
The learners should also have be allowed and encouraged to incorporate aspects of their cultural background or beliefs into their learning process and even into the self care, as this helps to individualize the learning. The elderly learner is most likely to want to incorporate some aspect of cultural background into the self care process, such as religious devotion, music, etc.
Knowledge
Additionally, learning should build on prior knowledge that the learner has and instructors should make an effort to know what prior understanding or level of education the learner has so that the instructor can teach to this level. The elderly learner is most likely to have achieved some education in life but is also most likely to require simple instruction so is to be approached at the same level as the child learner unless otherwise indicated by the learner.
Educational Philosophy
The educational philosophy to be used for this project is Essentialism, which allows the instructor to get to the essence of teaching—which is to enable the learner to acquire a skill that is needed. The aim of this philosophy is to help the learn achieve mastery of the subject that is being taught. This philosophy aligns with the theoretical approach used for this project, which is the humanistic approach.
Educational Theory
The theory that is used for this project is the Humanistic Learning Theory. The humanistic theory of learning puts the recipient of the learning at the center of the learning process—i.e., the individual is the focus rather than the environment, the nurse, the situation, etc. This stems from the person-centered approach that Rogers (1951) developed, describing it as “the best vantage point for understanding behavior is from the internal frame of reference of the individual” (p. 495).
Computer-assisted instruction theory is also utilized as it allows learners to use the technology that is available in the Digital Age to facilitate their self care process. As Bartholomew, Gold, Parcel et al. (2000) show, computer assisted instruction theory is helpful in teaching lessons to students of all ages as it is a tool, like a calculator, that helps make processing problems easier for the learner.
The main advantages of humanistic theory are that: 1) it offers a learner-centered approach to learning that allows the needs of the individual learner to be front and center, and 2) it assists in the development of adequate motivation, relationship-building, communication, and self-efficacy (Halstead, 2007).
When individualizing a self care practice to fit a patient lifestyle, humanistic theory is especially helpful because it allows the patient’s needs to be identified and addressed first and foremost. Humanistic theory allows the nurse to identify the needs of the patient first; so instead of simply recommending the right course of action, indifferent to the patient’s underlying needs, the nurse can help the patient to identify issues that may be leading to a desire to eat unhealthy foods and avoid exercise. Perhaps the patient is depressed about something, or has a lot of anxiety. The nurse can help to address underlying issues through the humanistic theory and then implement the right course of action to help address the patient’s health issue. Humanistic theory also facilitates the essentialist philosophy by providing the instructor the perspective to be able to center the learning process on the individual learner’s needs in order to achieve the objective, which is to communicate the knowledge needed to gain the skill of self care for the patient. It can be combined with computer-assisted instruction theory in order to provide a comprehensive approach that both gives the learner the assurance needed to conduct effective self care and the tools to do so, too.

Part 2: Goals & Objectives
Goals
A goal is defined by Bastable (2014) as the “end of the teaching-learning process” (p. 425). Thus, the goal of this project is to empower the learner to obtain the ability to be self-actualized. Specifically, the goal is to teach elderly patients how to care for themselves when they have a diagnosis of congestive heart failure.
Objectives
The main objectives of this project are to provide self care instruction that focuses on: physiological stability and the management of symptoms. Specific objectives include:
1) Adhering to the prescribed medication regimen
2) Adhering to a low-sodium diet
3) Restricting fluid intake
4) Seeking the help of a health care provider when necessary
Objective 1. Following a 20-minute teaching session on using the personal health record system (PHR), the learner will list the patient’s prescribed medication regimen that is posted in the PHR portal. The learning domains for this objective are cognitive and psychomotor.
Objective 2. Following a 20-minute teaching session on identifying the sodium content of a meal using Google, the learner will list the sodium content of the day’s meals and identify whether they are under or over the prescribed sodium intake levels. The learning domains for this objective are cognitive and psychomotor.
Objective 3. Following a 20-minute teaching session on restricting fluid intake, the learner will identify what fluids are okay to imbibe, which are not, and what the proscribed recommended intakes are. The learning domains for this objective are cognitive and psychomotor.
Objective 4. Following a 20-minute teaching session on when it is necessary to seek medical assistance, the learner will respond to 4 hypothetical scenarios and tell whether it is or is not necessary for the patient to seek medical assistance. The learning domain for these supporting objectives is affective.
Supporting Objectives
The supporting objectives that assist achievement of the main objective are:
Supporting objectives 1. a) Following a 10-minute tutorial on how to use the PHR, the learner will be able to log in and access the patient’s medical records and pull up the prescribed medical regimen; and b) Following a 10-minute tutorial on when and how to re-order medications, the learner will be able to demonstrate how to ensure that prescriptions never run out. The learning domains for these supporting objectives are cognitive, psychomotor and affective.
Supporting objectives 2. a) Following a 10-minute tutorial on how to use Google, the learner will be able to do a Google search for a meal to find sodium levels; b) Following a 10-minute tutorial, the learner will be able to compile a notebook of low sodium meals. The learning domain for these supporting objectives are cognitive and psychomotor and affective.
Supporting objectives 3. a) Following a 10-minute tutorial, the learner will be able to monitor fluid intake levels using a graph and notebook; b) Following a 10-minute tutorial, the leaner will be able to develop a schedule of when to take fluids. The learning domain for these objectives are cognitive and psychomotor.
Supporting objectives 4. a) Following a 5-minute tutorial, the learner will be able to use a device that alerts a designated health care provider in the case of emergency; b) Following a 15-minute tutorial, the learner will be able to role play correctly a scenario in which medical assistance is required and in which medical assistance is not required (with the correct action taken to resolve the issue when medical assistance is required and when no medical assistance is required). The learning domain for these supporting objectives is affective.

Part 3—Teaching Plan and Evaluation
Instructional Strategies
The instructional strategies that will be used for teaching will be: 1) one-to-one instruction, 2) demonstration, and 3) role playing.
Objective 1 and accompanying supporting objectives. One-to-one instruction will be used for this objective along with demonstration to show how the PHR portal is accessed, how to maneuver through it and find information, and how to know when it is time to re-order a prescription.
Objective 2 and accompanying supporting objectives. One-to-one instruction will be used for this objective along with demonstration, self-learning and role-playing to show how to use Google to search for salt content of planned meals, and how to develop a meal plan based on the findings of these searches. A role-playing exercise will be conducted in which the learner names a meal to be planned, then uses Google to search the salt content.
Objective 3 and accompanying supporting objectives. One-to-one instruction will be used for this objective along with demonstration. The instructor will provide a chart that shows what levels of fluids are acceptable and add it to the PHR. The instructor will also demonstrate how to create a fluids schedule.
Objective 4 and accompanying supporting objectives. One-to-one instruction will be used for this objective along with demonstration and role-playing. The instructor will instruct the learner on the types of situations that should alert the patient to the need for medical assistance and how to seek it. The instructor and learner will role play various scenarios so that the learner can become familiar with situations that require medical assistance and ones that do not and what the appropriate course of action should be for each.
Learning Activities
The overall time frame for the project is 1 week or 4 sessions of an hour each. The overall instruction for each session should not take an hour but time should be allotted for using the humanistic theory of instruction so that the instructor can get to know the learner better and incorporate aspects of the learner’s background into each lesson. An hour for each session also allows for an appropriate amount of time for each component of the learning content and allows for instances in which the individual requires some deviation during the course of instruction.
Objective 1 and accompanying supporting objectives. Background knowledge probe, concept review, reconsidering, and What? So What? Now What?
Objective 2 and accompanying supporting objectives. Background knowledge probe, concept review, role playing, and What? So What? Now What?
Objective 3 and accompanying supporting objectives. Background knowledge probe, concept review, and What? So What? Now What?
Objective 4 and accompanying supporting objectives. Background knowledge probe, concept review, role playing, and What? So What? Now What?
Evaluation Method
Objective 1 and accompanying supporting objectives. Direct observation and self-assessment.
Objective 2 and accompanying supporting objectives. Direct observation and self-assessment.
Objective 3 and accompanying supporting objectives. Direct observation and self-assessment.
Objective 4 and accompanying supporting objectives. Direct observation and self-assessment.
Narrative Support
Instructional strategies. For the objectives and accompanying supporting objectives, one-to-one instruction is provided along with demonstration and role-playing because these facilitate the humanistic instructional and computer-assisted learning approaches, and they also fill the gap in self care instruction identified by Dickson and Riegel (2009), Riegel et al. (2016) and Harkness et al. (2015). One-to-one instruction gives the learner the personalized, individualized attention that elderly patients require when learning self care methods. Demonstration allows the instructor to provide a slow, methodical example of exactly how the learner is to engage in the self care process, which is helpful for elderly patients learning self care (Riegel et al., 2016). And role playing helps the patient learner to actively engage in the learning process and learn by doing, which is identified by Dickson and Riegel (2009) as being an area of instruction that is particularly needed in self care instruction.
Learning activities. The learning activities—background knowledge probe, concept review, reconsidering, and What? So What? Now What?—each contributes to the learning process by focusing on a specific aspect of acquisition. The background knowledge probe allows the instructor to identify and build on prior knowledge (Bastable, 2014). The concept review allows the instructor to go back over with the learner the ideas and methods that were just demonstrated. Reconsidering provides the learner the opportunity to think critically about situations and contexts so as to develop critical thinking skills and demonstrate comprehension of the lessons and concepts associated with them. Role playing helps to give the learner the confidence needed to be able to carry out the self care processes that have been taught (Bastable, 2014; Dickson & Riegel, 2009). And What? So What? Now What? is an opportunity for the learner to demonstrate the ability to examine a situation, assess the variables, and develop a solution to the issue at hand. This type of activity is particularly well suited to moments when the learner may be planning a meal and finds, through a Google search, that the sodium content is too high. It can also be appropriate for posing a scenario in which the learner finds that a medication is about to run out in a week.
Evaluation methods. Direct observation can be administered by the instruction in a pass/fail manner: either the learner will be able to demonstrate competence by accomplishing the task-oriented learning activity, in which case the learner passes the evaluation, or the learner will demonstrate a lack of competence by not failing the task-oriented learning activity, in which case the instructor will provide further demonstration to support the learner’s understanding of the concepts (Halstead, 2007).
Self-assessment is recommended because this challenges the learner to be self-aware, engaged, and to obtain self-efficacy and self-actualization. The instructor can provide feedback on the spot after the learner engages in self-assessment to facilitate the evaluation process (Bastable, 2014).


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