Learning How to Give Caring

Fundamental to providers learning how to give caring is their ability to challenge traditional stereotyping or labeling of the patient as a chief complaint, a diagnosis, a disease, or a passive recipient of care. For a partnership to be formed, the provider must see the patient first as a person. In doing so, the provider appreciates and respects the patient’s individuality and subjective response to the presenting health care need(s). It must also be recognized that the patient’s subjective response to illness or a health care problem will be influenced by values and beliefs, which may differ from those of the provider.

Seeing the patient as a person requires communication, which is essential to learning how to give caring (Green-Hernandez, 1997). Communication goes beyond the spoken word. It involves one person sending a message and another receiving that message. Through communication, both providers and patients let each other know that they are willing and available to enter into a caring partnership. Providers must be open to receiving a response from patients about their willingness and level of ability to participate in their own care. With this understanding, the provider and the patient will be able to define what the patient’s health care needs are, and how they will be met. This partnership will be defined and redefined over time (Garofalo & Murphy, 2014).

An ongoing concern of providers is the brevity of health care encounters. How realistic is it, in a 10- to 15-minute visit, to communicate to a patient one’s willingness and availability to enter into a caring partnership? Regardless of the length of the visit, providers still retain control over how they interact with patients. Simple approaches to interactions with patients, such as those in Table 1.1, communicate caring and therapeutic intent. These are some of the many approaches that will communicate to patients that they are the focus of the encounter. This caring process is a reflection of using the time the provider has with the patient for the patient (Flocke, Gordon, & Pomiecko, 2006; Flocke, Kelly, & Highland, 2009; Green-Hernandez, 1997; Singleton, 2000, 2002).

Re-Visioning Compliance

From the previous discussion, it follows that providers who learn how to be caring have effectively learned how to use themselves therapeutically. To do this, providers must recognize the importance of what they bring to patient-centered care. This requires both self-awareness and learning how to use the different strategies discussed to be reflective practitioners. These practitioners reflect on their practice, using patient encounters to critique themselves in order to be more effective in their use of self. Reflective practice is a skill that requires conscious self-study and development over time.

Learning how to care necessitates changing preexisting perspectives that may be detrimental to the patient–provider relationship. One such critical perspective that must be revisited is that of paternalistic relationships, in which the provider uses power and authority to prescribe care, seeking compliance from the patient. In these scenarios, true communication does not take place. These patients are at risk of being labeled “noncompliant” if they do not carry out the provider’s orders. Because of the lack of communication, it is unlikely that any understanding will be gained of why the patient did not follow through with the plan of care. With the exception of situations that involve the immediate safety or protection of the patient, provider, family, or community, the word “noncompliant” expresses an attitude inconsistent with patient-centered care. Providers who value patient-centered care continue to work toward replacing this word with the word and perspective of participation, reflecting a changing paradigm from paternalism to caring for, activating, and engaging patients in their own health. Thus, trusting partnerships are developed (Green, Cifuentes, Glasgow, & Stange, 2008; Simons, Flynn, & Flocke, 2007).

Technical Proficiency

Technical proficiency results from developing the psychomotor skill repertoire required for practice. There are skills that will be common to all primary care providers and others that may be specific to providers working with different patient populations, or to the focus and scope of services in their primary care practice group. Providers need to identify the skills necessary to their practice. Learning and performing skills help providers to gain a feeling of technical competence. Necessary skills will change over time, both in how they are performed and in the skills required. Providers must keep abreast of these changes to maintain technical proficiency.

Professional Competence

Professional competence is predicated on developing essential skills, including learning how to give caring, technical proficiency, and effectiveness in coordinating care. Coordinating care of patients may include interprofessional consultation, referral, or comanagement with the interprofessional team. Professional competence is the culmination of achieving and balancing these skills.

Interprofessional Practice

The relationships among provider and colleagues, although different from provider–patient relationships, are central to providing primary care. Relationships among interprofessional colleagues can offer valuable perspectives on assisting patients in meeting their health care needs. Providers must trust the contributions that can be made through consultation with or referral to their interprofessional colleagues. For this trust to develop, providers have to believe that interprofessional practice will improve patient outcomes. They also need to be willing to gain greater understanding of, insight into, and respect for other disciplines, and the contribution they can make to patient outcomes (Singleton & Green-Hernandez, 1998).

Barriers to interprofessional education and practice include negative attitudes and inaccurate perceptions of faculty and providers toward the benefits of interprofessional education and practice. It is interesting to note, and certainly holds hope, that students of the health care disciplines view interprofessional education and clinical practice experiences positively and actively seek to participate in them. Several benefits of interprofessional practice have been identified. These include greater patient satisfaction, better outcomes, and cost efficiency. Without confronting these barriers, the benefits of interprofessional primary care will not be realized (Centers for Disease Control and Prevention [CDC], 2009a, b).

A caring, trusting patient–provider relationship is the foundation for a patient-centered approach to proactive primary care. Through this approach, providers come to truly know their patients. This facilitates accurate and comprehensive assessment of the patient. Patient-centered care incorporates more than traditional, formalized assessment. From its initiation, the patient is recognized as having expert knowledge of his or her health care need(s). Through empowering the patient in a health care system that traditionally disempowers, negotiation of care occurs through active participation with the patient. This relationship mirrors contemporary thought representing the idea of health stewardship (Teisberg et al., 2009). Health stewardship represents a meta-level of responsibility for patient-centered care, which involves the responsible use of resources for all patients to foster health.

Maximizing Self-Care

In its most simplistic sense, self-care means taking care of oneself. The processes involved—commitment and motivation of individuals in taking care of themselves—are not yet well understood. Motivation, however, is recognized as a complex phenomenon that is internally driven. Although providers may not be able to directly motivate their patients to care for themselves, they can create a climate to encourage motivation. Educating patients is an important strategy providers can use to encourage patients in care-of-self and to achieve positive health outcomes. To effectively use health education as a strategy, patients should be approached based on their learning styles.

Assessing Learning Style for Health Education

Much is written concerning how the primary care provider can best offer health education in a busy office or clinic setting. The realities of managing this process can be especially challenging when there is little time for teaching during the visit, let alone time for assessing learning needs regarding growth and development, health promotion, disease prevention, and illness/disease management. The following section provides a guide for assessing a patient’s learning style, while also providing several suggested teaching intervention techniques.

Basic Necessities for Health Education

The patient’s and family’s understanding is critical to their success in participating in developing and carrying out a plan. The evaluation component of the plan’s outcome is tied to this comprehension. Key areas of knowledge to be evaluated include:

Learning style is not a one-dimensional concept. It is made up of many elements, including the learner’s reading comprehension and verbal understanding levels, developmental level, learning style, and emotional status. Basic personality and learning style also influence the learner’s ability to take in and use new information. A further complication to learning ability may be the fact that, when uninvited information is given (information the patient may not wish to hear or is unwilling to hear), its acceptance and integration may not take place (Etz et al., 2008; Flocke, Crabtree, & Stange, 2007).

Reading Levels and Content Understanding

American adults’ reading comprehension and the correlation of that ability with health literacy were last surveyed in 2003 by the U.S. Department of Education. This study uncovered content that is directly related to possible health outcomes in primary care. A slight majority of adults (53%) have intermediate-level literacy. That is, they can understand 67% of what is read. A further 12% are proficient in this understanding. Conversely, 22% have only basic comprehension, while 14% of adults are below basic in their literacy (2003). These statistics correlate with respondents’ self-reports of overall health. Respondents whose literacy scored at the below basic level reported that their overall health was poor, compared to the good or excellent ratings self-ascribed by Intermediate and Proficient individuals.

Primary care providers (PCPs) need to be aware of these levels in order to provide interventions that meet the patient at his or her level of understanding, including his or her self-assessment of personal health. Key to this provision is the PCP’s recognition of the patient’s capability of participating in the learning plan. Table 1.2 presents some of the differences between below basic and proficient learners. The reader can use these differences to best identify where patients who are basic as well as those who are intermediate learners best fit, as some may straddle a level lower or higher than their general capability. Suggestions for how to plan accessible patient teaching are also included.

Poor Health Knowledge

The PCP who cares for patients whose literacy skill is challenged may be at risk of delivering care that turns out to be unexpected by the patient. For example, in preparing to do a particular procedure such as incision and drainage of a wound, the PCP first has to get the patient sign a document of consent. Included in that document is an explanation of a local anesthetic to be used and how it is to be delivered. A patient’s response to needle delivery of the local anesthetic may be totally unexpected by the PCP, as this part of the procedure was described in the patient consent form. Sudore et al. (2006) found that patient outcomes were directly influenced by their understanding of the consent form signed prior to procedures.

Of even more concern is the risk patients can face in management of their disease if their understanding of health behaviors that led to their problem is not complete or accurate. If not able to read instructions, patients’ self-care in medication dosing and frequency may place them at risk of negative health outcomes. Schillinger, Wang, Rodriguez, Bindman, and Machtinger (2006) found this in their examination of the impact patients’ literacy skill had on safe anticoagulation therapy.

Also of concern is the knowledge that patients with low literacy skills are less able to read and understand a medication label, which affects their ability to take medication as directed (Davis et al., 2006). Such misunderstanding can extend into the acquisition of health behaviors, as adults with limited literacy skills are also less able to access the health care delivery system for health screening (Bennett, Chen, Soroui, & White, 2009).

The Patient Living With Comorbid Conditions

It is important that the PCP identify each patient’s developmental capability for learning. Just as very young adults may have requirements that differ from those of the older people, comorbidity can also influence the learning continuum. Life experience can help to narrow the gap between Below Basic and, for example, Intermediate or even Proficient learners. The PCP can help to ensure learner success by integrating such experience into the teaching plan. An older patient with a long history of heart disease who has developed a new cancer will bring very different needs to his or her learning, compared to the young adult with just-discovered hyperlipidemia. A single mother caring for physically and intellectually challenged children may need to have some of the issues faced by these youngsters addressed before she can engage in her own new-diabetic teaching.

There are several tools that can be used to support literacy and communication of health information. Two commonly used tools are the Simple Measure of Gobbledygook (SMOG) and Rapid Estimate of Adult Literacy in Medicine (REALM) tools. The CDC offers a comprehensive guide, Simply Put (2009), to help distill complicated health information into written materials that patients can relate to and understand. This excellent guide, which included the use of the SMOG tool to assess the readability level of written materials, can be easily retrieved and is available as a PDF download (see the reference list to obtain this guide). Another short-item instrument that can be used for literacy screening is the REALM-R, which can be accessed at www.ahrq.gov/legacy/pharmhealthlit/documents/realm-r.htm.

Meeting Learning Needs

“The teachable moment” means that the provider uses every possible opportunity to convey the message. In primary care, this message focuses on all aspects of health promotion and disease prevention. Teaching–learning can be contagious. A health message may reach a patient because of its relevance to the patient or to the patient’s family and friends. Having a selection of pamphlets available to patients in the waiting room helps to ensure that they pass on the “correct” version of this message. Teaching messages can be reinforced in the waiting room through use of colorful health posters and a variety of pamphlets. Non-English versions should be displayed if appropriate to the patient population.

Consider assigning different clinic staff the responsibility of periodically changing posters as well as replenishing and updating the health teaching literature so that frequent clinic users will be exposed to more than one or two ongoing messages. Ongoing messages may include, for example, posters and literature related to smoking and alcohol use, safer sex, healthy babies, diabetes, cholesterol, and heart disease. Ideally, posters should be changed every few months. These simple acts can add interest to the patient’s wait, while reinforcing the messages providers wish to convey. People will peruse material new to them the first time. After that initial exposure, their interest must continue to be piqued if health messages are to be reinforced.

These strategies can also find their way into examining rooms or cubicles. Consider posting materials on wall space and ceilings. A cheerful poster displayed in an unexpected spot can be an especially powerful teaching strategy.

“The teachable moment” presents itself in many ways. For primary care providers, learning to make the most of a teachable moment may be the critical element in creating a climate to encourage patients in health promotion and disease prevention self-care. Teaching occurs at every patient encounter. The primary care provider must also assess the patient’s understanding of the information provided through the use of techniques such as teach-back. The teach-back process begins with the provider informing the patient that he or she (the primary care provider) wants to assess if he or she is doing an adequate job of educating the patient and developing a plan of care. The provider asks the patient to teach-back what the patient believes or understands about the topic. Open-ended questions are asked to assess a patient’s understanding and identify areas in need of clarification. Further education can then focus around areas about which the patient is uncertain. This interactive process should continue until the provider is confident that the patient has achieved a satisfactory level of comprehension, thus allowing the patient to make informed health care decision and work toward achieving positive health outcomes.