Address emotional barriers quickly

Pair detailed assessment with informal assessments

"Any kind of emotional upheaval is a powerful distraction from learning," says Yvonne Brookes, patient education liaison at Baptist Health Systems of South Florida in Miami. When patients are ill or in pain, they are usually focused on their physical and emotional stress and can be difficult to teach.

Anxiety and depression are two common emotions patients experience when faced with illness, says Brookes. In addition, they might be in a state of denial, refusing to acknowledge the existence of a health problem.

Anger also can be a stumbling block to learning. While the underlying cause of the anger usually is the disease, a patient’s anger can be triggered by a number of factors, including something the patient’s physician has done, says Molly Hottinger, RN, PHN, an educator in the patient learning center at Fairview University Medical Center in Minneapolis.

When patients feel there is too much to learn to manage the disease, they become overwhelmed, and this feeling also can hamper the education process. They may not be open to learning new skills, such as injecting a drug, says Hottinger. The anger or feeling of being overwhelmed needs to dissipate first.

If teaching is to take place, emotional barriers must be addressed quickly, agrees Brookes. When social, financial, or environmental issues are causing worries and distractions, the appropriate discipline needs to be called in to work with the patient. For example, if a mother is worried about the care of her children while she is in the hospital, the social work department can be notified and asked for help.

Assessment uncovers barriers

To identify barriers and address them in a timely manner, a good initial assessment must be conducted, followed by more informal assessments before teaching takes place, says Brookes.

Many hospitals have added social and cultural questions to the assessment that is completed upon admission so emotional issues can be better identified in a timely manner. For example, patients are asked about such worries as financial hardships, and how they see their illness interfering with their life.

Although nurses can’t go through the long assessment each time they want to teach the patient, they can ask questions to see if issues causing emotional distress have been addressed, says Brookes. For example, nurses can ask whether the social worker has been to see the patient.

Quick questions also can help identify emotional barriers that still need to be resolved before teaching can take place. To see if the patient is in denial, ask the patient to explain why he or she is in the hospital, says Brookes. If the patient’s answer doesn’t coincide with the physician’s reason for admitting the patient, this could signal an unwillingness to accept the diagnosis.

Watch a patient’s body language as well, says Hottinger. When people display crossed arms, tight lips, and poor eye contact, they could be angry. "I often ask if they are ready to learn or if there is something bothering them," she explains. Let the patient explain what is making him or her angry and sympathize with the patient, but don’t feed the anger. Listening is an important skill every educator needs to develop, she says.

Patients who are overwhelmed need to feel confident. While they may understand what they are being taught, they don’t always feel competent to carry it out, says Zeev Neuwirth, MD, assistant professor of medicine at Mount Sinai Medical School and faculty physician at Lenox Hill Hospital in New York City.

For example, patients may understand the importance of changing their diet in an effort to manage their disease. However, they may not be able to make the necessary changes. The required food might be too expensive or it might not be readily available. In addition to asking if the information makes sense to the patient, ask if the patient can do what you have asked, advises Neuwirth.

Also, patients might become more willing to attempt behavior change if the educator can provide the patient with a different point of view. For example, a patient asked to start an exercise program may see all kinds of reasons why that can’t happen, such as a high workload or too many social obligations. Yet, an educator can take the facts the patient provides and paint a different picture, says Neuwirth. For example, exercise could provide an opportunity to get away from the office and ease some of the patient’s stress.

When teaching patients a skill, begin with the easy tasks first to build confidence, says Hottinger. Use a lot of positive reinforcement. When patients are having trouble learning a task, point out what they are doing well. By building on successes, the patient will realize he or she can master the skill, she explains.

Timing is very important, says Brookes. "In the beginning, it may be more important to help patients express their fears instead of pushing them to receive information," she says.


For more information on identifying and overcoming emotional barriers, contact:

Yvonne Brookes, RN, Patient Education Liaison, Baptist Health Systems of South Florida, 6200 SW 73rd St., Miami, FL 33143-4989. Telephone: (305) 242-3530. Fax: (305) 242-3578. E-mail: YvonneB@BHSSF.ORG.

Molly Hottinger, RN, PHN, Educator, Patient Learning Center, Fairview University Medical Center, University Campus, 420 Delaware St. SE, Box 603, Minneapolis, MN 55455. Telephone: (612) 626-4894. Fax: (612) 624-0651.

Zeev Neuwirth, MD, Faculty Physician, Lenox Hill Hospital, Department of Internal Medicine, 624 Blackhall, 100 East 77th St., New York, NY 10021. Telephone: (212) 434-2104. Fax: (212) 434-2446.