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Education of the Patient with Neuropathic Limb

Elizabeth A. Yetzer, MA, MSN, CRRN

In this presentation, three aspects of education are discussed: the education of the orthotist in the principles of patient teaching; the education of other health care professionals about the role of the orthotist in the care of the patient with neuropathic foot and establishing an exchange of information; and the role of the orthotist in education of the patient and family or caregiver.

TYPES OF EDUCATION

ORTHOTIST EDUCATION

Undergraduate and training programs of health care professionals need to include formal education in effective patient education.¹ Because the orthotist will be interacting with the patient and family or caregiver, he or she should have knowledge of the principles of adult education. Even if the patient is a child, the orthotist will also be educating the parent or caregiver of the child.

Adults are self-directed. Many seek information from a variety of sources: professionals, family and friends, support groups, and the Internet. Because some of this information is not supported by facts, the orthotist may need to assist the patient to correct misconceptions. Adults bring life experiences and attitudes to a new situation. The new learning needs to have a connection with older experiences. Adults need to see the relevance of the information and change in life style.² Many patients with diabetes do not think they are at risk for foot skin breakdown, and therefore do not see the relevance of foot care or the need for special shoes.³ These principles of adult education need to be considered when planning the goals and objectives of learning with the patient.

MEDICAL EDUCATION

Boulton⁴ cites several studies that showed one in five diabetic foot ulcers are the result of some form of professional mismanagement. Examples of mismanagement were failure of the professional to examine the patient's feet or to do noninvasive screening; lack of recognition of symptoms of neuropathy; delay in referral; and inappropriate footwear provided by the orthotist. There needs to be information sharing among the orthotist and other health care professionals. This exchange would improve patient care because the orthotist would have increased information about the foot problems of the patient and the plan for the patient's care. Examples of information the orthotist can share with the health care professional include:

After the patient is fitted with the orthotic device or custom shoe, information such as the type of device or shoe, the patient's reaction to the device or shoe, and the patient education given should be shared with the health care professional.

PATIENT AND FAMILY EDUCATION

Health care professionals are the principal providers of care and the principal source of knowledge for most patients.¹ Every health care professional interacting with the patient is responsible for patient education, which provides information to the patient, evaluates the patient's understanding of the information, and supplements or reviews the information as necessary.

Patient education, as defined by Piccininni and Drover,¹ is "the process by which a patient learns or acquires knowledge about his or her health status or condition and may involve learning in the cognitive, affective, and/or psychomotor domains" (p 43). Chin² identifies the cognitive domain as activities of knowledge comprehension, processing, and recalling information; affective domain involves focusing on feelings, values, and attitudes; and psychomotor domain involves performance, skilled movements, and motor function. Examples of patient education in the cognitive domain include stating the purpose of foot and nail care or the causes of a foot ulcer. Affective domain learning helps the patient verbalize and deal with feelings about a diagnosis and accept responsibility for self-care. Examples of psychomotor domain skills are the patient demonstrating foot inspection and wound care.

The purposes of patient education include improving knowledge regarding foot problems,⁵ reducing the incidence of ulceration and amputation,⁴ preventing diabetic foot complications and assisting in early detection of problems,⁶ and redefining the role of the patient as partner in medical decision making.^1,7,8 Patient education is mandated by health care accrediting agencies and reimbursement agencies.⁹

No randomized clinical trials related to patient education were found in the literature search. May⁹ reported that most research in patient education focused on efficiency of instruction in the care of the patient with specific health problems, such as diabetes, and pre- and postoperative management. Other studies evaluated specific educational methods, such as written instructions, videotapes, and one-on-one versus group teaching. Patient reading comprehension and understanding of written educational materials were also evaluated. Most studies were of small groups at one specific center, raising the question of applicability to larger groups. It is generally accepted that research supports the value of a well-developed educational program.

One study⁵ evaluated the impact of diabetic foot education of only high-risk patients at one Veterans Administration center on patient knowledge and satisfaction. Three tools were used to assess the patient's knowledge about foot care, their satisfaction with their care using the Patient Satisfaction Questionnaire, and their independence in activities of daily living. The intervention was a comprehensive educational program presented in two sessions of 2 hours each. The tools were used at the first session and repeated 3 months later. The results of the study indicated improvement in foot care knowledge for patients who attended both educational sessions. These patients also reported improved satisfaction with foot care. An important finding was the patients considered the educational program inaccessible because of time and distance (an average distance of 54 miles) to the clinic. The patients would rather attend programs in conjunction with regularly scheduled clinic visits. The authors suggested that additional research should focus on improving the patient educational sessions.

This discussion on patient and family/caregiver education focuses on suggested content for teaching, the use of and evaluation of instructional materials, and documentation of the teaching/learning process. The family or caregivers are included because they can assist the patient in remembering information, encourage the patient to follow the steps in care, or provide the care needed by the patient. Boulton⁴ stated that few elderly patients are able to perform foot examinations or foot care, so education of the family and caregiver is necessary.

To develop an educational program, ask the following questions: Who is the right person to teach? It may be the patient and/or the family/caregiver. When is the right time to teach? Usually this is when the patient is ready to learn. Content may have to be reviewed several times because the patient was not ready to learn when the content first was presented. What is the right information in the right amount to teach? Skills, such as wound care, may have to be broken into smaller tasks that are easier to learn. What is the right method of instruction for this patient or family? There needs to be an evaluation of their learning style to determine if it is visual, auditory, or tactile. A comprehensive educational program should use a variety of educational tools, have active participation by the patient and caregivers, and evaluate the learner's achievement and the effectiveness of the educational program.⁹

CONTENT TO BE TAUGHT

The orthotist should identify what the patient already knows, what the patient thinks he/she needs and wants to know, and any incorrect information the patient may have. Using the principles of adult education, the orthotist and the patient develop objectives for learning. The objectives have to be measurable to evaluate if the objective has been met. To develop measurable objectives, fill in the blank of the following: at the end of the teaching session, the patient will be able to _______. Examples are: The patient will be able to demonstrate foot inspection methods, or the patient is able to state when to notify the health care provider of a problem. Examples of content for patient education include:

1. Prevention of foot skin breakdown by identifying common causes.^10,11

2. Proper foot and nail care.¹²

3. Buying shoes and socks, and breaking in shoes.

4. Care of orthotic devices/shoes and when to replace.

5. When to seek medical care.

6. Wound care.^12,13

7. Relapse prevention.

8. Implications of loss of pain sensation.¹⁰

The teaching/learning process also includes evaluating the patient's understanding of the information presented. This can be as simple as asking the patient or the family/caregiver to demonstrate or describe a procedure such as foot care, to list the signs of infection, or to identify when the patient should contact the orthotist or other health care professional. One tool to accomplish these objectives is represented in Table 1 .

USE OF INSTRUCTIONAL MATERIALS

Instructional materials, such as handouts, booklets, and videotapes, are used to supplement the instruction and provide resources. They do not replace the instruction of the orthotist. Patients often do not remember what was taught or receive conflicting advice from family, advertising, or other sources.⁸ The instructional material is to remind them of the steps of a procedure, such as foot care, and to reinforce information by answering questions or encouraging the patient to ask questions. Instructional materials need to be evaluated for correct content, reading level, ease of understanding, and reliability.

Evaluation of materials should include:

1. Appropriate reading level. Smith and Smith¹⁴ evaluated the readability of prosthetic patient education publications using the Gram-mat-ik IV software program, and the reading grade level using the Flesch Reading Ease scale.¹⁵ They found that most brochures available for patient education were above the level of comprehension of the patient requiring a prosthetic. They suggested that other factors to be considered are cultural factors, visual attractiveness, legibility of letters, readable print size, and consistent format.

2. Cultural relevance and ease of understanding. Ledda et al.⁶ identified that, although educating people with diabetes to care for their feet is key to prevention and early detection of podiatric problems, few diabetic education programs for foot self-care have been developed, evaluated, or targeted for a special population. Their study reported the development and evaluation of a foot self-care program for African Americans with diabetes. The program consisted of a 15-minute, one-on-one orientation session with a diabetes nurse educator and a take-home foot self-care packet, including a large hand mirror. The orientation session reviewed the program components and administered a 16-item foot-care behavioral survey. The booklet had a reading level at or below sixth grade and illustrations of African Americans with diabetes performing foot care. A follow-up assessment was conducted by a telephone interview 2 to 3 weeks later with a $10 incentive for completing the telephone interview. The interview asked the participant to provide an overall rating of the program and usefulness of the materials. The findings of the study included an overall rating of the program of good to excellent, favorable reaction to the instruction booklet, positive response to the mirror, and a positive effect on daily foot-care practices. They also found that the Afrocentricity of the materials might have been too restrictive for some communities and that multiethnic material may be preferable.

3. Readable print size and language. Aging and diabetes affect eyesight, making reading difficult. Evaluate the materials for the size of print and the amount of information that must be read. Information can be presented in outline format containing only the important points. Some patients may benefit from materials that are pictures or drawings of the activity with limited reading required. Evaluate the information for medical terms that may not be known or understood by the patient. If you ask the patient only "Do you understand?" they will smile and nod "yes," rather than be thought of as stupid. It would be better to ask the patient to repeat or demonstrate or explain key concepts.

4. Correct content. As methods, procedures, and materials change, patient education materials need to be evaluated and updated. Evaluation should include if this method or procedure is based on research or best practices, or whether it is merely "the way it has always been done." The orthotist needs to continually update the knowledge, information, and materials used in patient and family education. Some patients are interested in a summary of information, whereas others want details. Educational materials should consider the needs of the individual by providing easy-to-read summaries, as well as information in greater depth. Patient software is now available to customize handouts.⁸

5. Reliable sources. Patients receive their information about health care from multiple sources, such as diseaserelated organizations, pharmaceutical companies, distributors of health-related products, and the Internet. Health care professionals need to help the patient evaluate the information for correctness and reliability and differentiate between advertisement and factual data.⁹

DOCUMENTATION

The purpose of documentation is to record the care and education given to the patient and family/caregiver, justify the time spent with the patient, and fulfill requirements of third party payers for reimbursement. Documentation also promotes continuity of patient teaching because it identifies the information that should be reinforced or reviewed and prevents duplication of effort. Documentation may protect the staff from legal issues.

Documentation should include the topics covered in the instruction, evaluation of the patient's understanding of the content, and a listing of the instructional materials given to the patient.

Two types of documentation are progress notes and checklists. The progress note provides a written description of what was done and the patient's reaction or understanding. An example would be: "Patient given custom molded shoes. Discussed with patient techniques of foot inspection for pressure area and wearing time for new shoes. At first patient refused shoes because they looked like old lady shoes. Discussed with patient the need for special shoes to prevent foot skin breakdown. Patient accepted shoes and was able to state reason for foot inspection for pressure points. Handout on foot inspection given to the patient."

The checklist is a common method of documenting the information taught, by whom and when, and the patient's understanding of the information ( Table 1 ). In this guideline, measurable educational objectives are listed that identify content to be taught. The date of the instruction and the initials of the instructor are identified. There is space to record the evaluation of the patient's knowledge and ability to meet the objective. The guideline also includes a space for review of the objectives in the future. The checklist can be used to review and reinforce instruction at the next patient interaction and to prevent duplication of effort. The use of a checklist is an easy and quick method of documentation.

Patient education provides the patient and family with information that can empower the patient to become a partner with the health care professional in the decision-making process for the treatment and management of his/her health status.^1,8

FUTURE RESEARCH

The following research questions are offered for consideration.

1. How many of the members of the Academy of Orthotists and Prosthetists (AAOP) are currently providing patient and family education? (See sample questionnaire in Table 2 .)

2. What methods could be identified for the orthotist to incorporate patient and family education into daily patient interactions?

3. Does the education on foot care given by the orthotist have a positive impact on the neuropathic patient's rate of foot ulceration or reulceration? In other words: does the education prevent foot ulcers or reduce the incidence of reulceration in the patient with neuropathy?

Correspondence to: Elizabeth A. Yetzer, MA, MSN, CRRN, 2650 West Meadowview, Anaheim, CA 92804; e-mail: .

ELIZABETH A. YETZER, MA, MSN, CRRN, is affiliated with Talbert Medical Group, Anaheim, California, and the Veterans Administration Healthcare System, Long Beach, California.

References:

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3. Harwell T, Helgerson S, Gohdes D, et al. Foot care practices, services and perceptions of risk among Medicare beneficiaries with diabetes at high and low risk for future foot complications. Foot Ankle Int 2001;22:734–738.
4. Boulton AJ. Why bother educating the multi-disciplinary team and the patient–the example of prevention of lower extremity amputation in diabetes. Patient Educ Counsel 1995;26:183–188.
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