Client focused education is a series of planned actions directed at producing specific learning outcomes requiring a systematic interaction between nurse and client. (Berman,2016). A nurse’s ability to think critically is vital in establishing actions, strategies, priorities and goals using clinical judgement to achieve desired patient outcomes, so to maintain optimal health. (Burton 2013) states that it is important to maintain a questioning attitude (Rosalinda 1994) The technique the nurse uses depends on the stage of development of each client, and their capacity to master physically, cognitively as well as psychosocially, it is important that the nurse assesses all these areas. (Burton, 2013).
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The development of a systematic, goal-based, structured technique, implemented through a precise nursing diagnosis and recognised patient concerns is important, therefore, involves nurses logistically assessing and identifying a diagnosis, setting goals and outcomes, interventions and evaluating the results. (Berman, 2016). This paper looks at Jessica, a 36-year old mother of 2 young children who is concerned about her risk of breast cancer due to her maternal Aunts diagnosis recently (refer to Appendix A). Adhering to the teaching process of Assessment, Diagnosis, Planning, Implementation and Evaluation (ADPIE), (Burton, 2013). the nurse formulated the following plan.
According to Burton (2013), Conducting a comprehensive assessment is the first of the five-phase nursing process compiled of collection of data, organisation of data, validation and documentation of all acquired data. (Berman,2016). The nurse building a therapeutic relationship with the client while gathering background information from medical history, and family while also showing empathy and ensuring clients feeling of security, (Burton, 2013). if Jessica is feeling intimidated, she may not participate fully. Ideally, the environment should be private, comfortable, climate controlled and well lit. (Berman, 2016). Burton (2013), Acknowledges that Jessica falls into middle adulthood stage of development, therefore she may be experiencing many changes both physically and emotionally. (Flippo, 2016). Adults in this stage are experiencing changes not only in the physical sense, they are facing psychological changes as well as changes in their social roles within family and society. The physical changes experienced by those at the middle adulthood stage have many intricate and variable characteristics.
Jessica’s maternal aunts’ recent diagnosis and treatment of breast cancer have Jessica wanting to be more proactive in her healthcare. Development psychosocially will be evaluated with the use of questions and answers (Burton, 2013). Recognises that the nurse will be required to ask questions relating to stress levels, coping mechanisms and ability, anxiety, network of support, family relationships, financial pressures, diet and exercise, as well as any other concerns client may have. This will assist the nurse to recognise Jessica’s desire to further educate herself. (Burton,2013).
(Beeken, Williams, Wardle & Croker (2016), suggests a systematic and structured approach to health promotion can save time and ensure desired outcomes are reached. With Santrock (2014), recognising that Jessica is in her middle adulthood stage of development, she may be encountering both physical and emotional changes.
Both Erikson and Levenson emphasised the central importance of close relationships such as Jessica’s husband in early and middle adulthood, her ability to share with one’s partner one’s life major milestones of adulthood is important. The more similar you are the more likely you are to stay together with the same interests etc.
Relationships between nurse and patient are recognised as “therapeutic relationships”
Development of this relationship aids the nurse in maintaining person-centred care.
To successfully meet the patient’s goals and needs the nurse must ensure trust and respect are achieved, Berman (2016), Demonstrating a sound understanding of both nursing and the nursing process and use of effective communication strategies, the nurse accepts responsibility professionally for the person in their care and can then focus on their goals and needs. Jessica is at the early adulthood stage of development, 18-40 years (Berk, 2018). at this stage of development, it shows the appearance of new skills happening.
Development is influenced by multiple, interacting biological, psychological, and social forces, many of which vary from person to person, leading to diverse pathways of change. Santrock (2014), states that the use of memory can improve one’s ability to remember, the nurse can assess Jessica’s memory by sharing a phrase and then asking for her to repeat it at a later stage. This will assist the nurse in determining her ability to learn. Nagy (2013) suggests that through the use of question and answer the nurse can determine the learning requirements and technique best suited to Jessica, her understanding and comprehension levels Using the question and answer process Jessica’s psychosocial development will be assessed. the nurse will be required to ask questions relating to her stress levels, ability to cope, support network, financial pressures, family network/support, relationship with family, also lifestyle questions such as smoking, drinking, exercise, nutrition and diet. This information assists the nurse to evaluate whether Jessica is ready to learn and actively participate in the process. Through question and answers, the nurse can assess the learning needs of Jessica, her level of understanding in regard to breast cancer and its risks, genetics and associated health implications. (Burton, 2013).
Upon completion of the assessment process, application of the nurse’s critical thinking will be applied, to evaluate all given information and facts. Jessica’s cognitive, physical and psychosocial levels will be considered, through the nurses use of judgement a nursing diagnosis can be applied. It is important for the nurse to make a factual diagnosis, and provide Jessica with successful strategies to assist with her concerns and self- education process. (Pérez Rivas, et al., 2015).
According to Tollefson (2016), an essential part of a nurse’s role is teaching, it is Competency 7.7 in the National Competency Standards for the Registered Nursing and Midwifery Board of Australia, (4th edition, 2006). Kaslingham, Ramalingam & Chinnavan (2014), recognises Bloom’s taxonomy as an outline used in the planning of educational strategies to establish an individual’s learning needs. Jessica conforms to the ‘Cognitive’ domain focusing on knowledge, using education, knowledge can be conveyed. The nursing diagnosis for Jessica can then be explained as, knowledge deficit (Cognitive), with further education required on breast cancer and the prevention and early detection processes.
The next stage in the process is to develop a teaching ‘plan’ encompassing one goal of a short term time frame and one that is a long-term time frame. (Burton, 2013).
The SMART acronym is referred to when formulating goals this relates to goals being specific measurable, attainable, relevant and timely, using all of these, the nurse can execute these goals. Short term goal to Familiarise by repetition, self-breast examination, Jessica will identify the connection between repetition to familiarise and become habitual. Furthermore, Jessica, over a six-month period will establish an understanding of a healthy nutritional intake in order to reduce risk factors associated with breast cancer, together with the nurse, Jessica will establish the high-risk foods and an elimination plan. Jessica will be ultimately in charge of her goals and the achievement of them through self-motivation (Burton,2013).
According to Erikson the middle age period of generativity is where parents will guide their children, versus stagnation, feeling they have achieved little for their offspring. Jessica may be wanting to set an example for her children, with a desire to educate her children in regard to self-awareness, breast examination, and healthy eating, cancer prevention, and diet. (Berk, 2018). Jessica is able to set an example to her children by actively monitoring both diet and exercise as well as self-breast exam (Santrock, 2014).
Cognitive development throughout adulthood is a time of expanding responsibilities, in not only one’s job, but also in a community, and at home, being described as somewhat of a juggling act, (Berk, 2018). Berk, (2018), continues to suggest in order to prevent and detect as early as possible, education around reducing cancer incidence and the ways to do so are important. Know the warning signs for cancer, schedule regular check-ups, avoid tobacco and limit alcohol consumption, avoid excessive exposure to the sun and avoid unnecessary x-ray exposure, maintain a healthy diet reducing intake of high cancer- risk foods, maintaining a healthy diet and staying active. (Beeken,2016).
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Witney, Hendricks, & Cope (2015), Documents Breast self-examination (BSE), is believed to be a valuable screening tool, BSE education can effectively increase knowledge about this practice and encourage attitudes that help facilitate self-screening. Research reveals that women who do not use BSE regularly have not been instructed how to do it and that Women know how to do it but do not perform regularly. With increasing numbers of people surviving cancer due to early detection and better treatments and preventative education, there is good evidence that a healthy diet (plant based with limited intake of high-calorie foods, red meats and processed meats), can help prevent cancer. (Witney, 2015).
Beeken (2016), explains that observational studies have shown that a low-fat, high- fibre diet is protective against the progression of breast cancer, and there is evidence of an increased risk of breast cancer recurrence from consuming a ‘western diet’ The mechanism linking dietary fat intake to cancer outcomes is not well understood but are thought to be related to sex hormones such as oestrogen, for example, dietary fat intake has been shown to increase levels of oestrogen in the blood which may promote the development of breast cancer in women (Flippo, 2016). States that people at risk for hereditary cancer of the breasts may consider having BRCA cancer susceptibility testing to assess a greater risk and that intensive screening is justified for the BRCA carriers and at-risk individuals aged below 40 years of age such as Jessica, screening such as clinical breast examination on a regular basis as well as mammography and MRI screening.
With (Perez Rivas et al.,2015), stating that nurses who followed the nursing process and provided all relevant testing and preventions available can lead to improvement of health in all populations and age groups. Crombie, K et al., (2014), explains that secondary prevention through methods of screening appears to be the most promising intervention towards breast cancer prevention and early detection. Breast cancer being the most common malignancy and the second leading cause of cancer mortality. Showing that over the past 3 decades breast cancer has increased, with the mortality rate decreasing, this being credited to more advanced knowledge of detection methods and examinations and the education thereof.
(Sodergren et al., 2018), mentions that education of the younger age groups and not just the women aged over 50 has provided a greater knowledge for the younger women in SBE, CBE, and other screening methods. Education is beneficial. (Berman, 2016). writes that Erikson puts Jessica in the “adulthood” stage of development, stating nurses can improve and strengthen a person’s task outcomes by providing the individual with opportunities that are both appropriate and encouraging to maintain interest and participation.
Once goals are established, implementation will commence through one on one participation, specifically directed towards Jessica’s stage of development, (Burton, 2013) educating Jessica about how incorporating self-breast examination regularly as well as healthy eating including elimination or reduction of cancer-causing foods and regular screening tests. (Feldhusen, 2017), suggests that the majority of women are unaware of the guidelines and recommendations in regard to the timing for baseline screening and the frequency of screening as well as the technologies that are available to them.
With Feldhuson (2017), presents breast health and diet, establishing foods such as meats and fats that may increase breast cancer risk as well as the National Cancer Institute provided dietary tips for eliminating harmful oils and foods. With a list of vegetables and fruits associated with a significant reduction in breast cancer occurrences. (Berk,2018). Shackelford, Weyhenmeyer & Mabus (2014), states that online education and support groups contribute to greater education and understanding of all preventative methods as well as early detection methods.
Munyaradzi, January, & Marodzika (2014), explains that after exploring the behavioural factors among females of childbearing ages approximately half of the woman, were aware of BSE however, only 7 percent of those females practised SBE. Lack of education was reported as the main contribution to these statistics. Shackelford, (2014), states that education sessions, be it individual or group based, educating participants on how to actively take part in their health care including question and answer sessions, have increased the knowledge of women in early detection and prevention of breast cancer.
Seven, Bahar, Akyuz, & Erdogan, (2015), goes on to explain that BSE was more likely to be practised in women attending group education classes as women were gaining greater confidence in their ability to detect breast lumps and other warning signs. Showing that education assisted women in the likelihood of receiving and sourcing preventative screening and diagnostic testing.
In conclusion, in order for the nurse to assess if all learning requirements have been met, Jessica will answer some carefully formulated questions (Burton, 2013). Jessica can briefly describe and discuss what she believes to be the implications of breast cancer, its heredity and implications on her and her future, and why she is desiring to educate herself further. Why does she feel that not only are exercise and diet important why, self-breast examination and the use of imaging and screening explaining how all can help her in the future to prevent breast cancer.
Physically Jessica can demonstrate the process for SBE and discuss foods that may be high risk for cancer and foods that are low risk and healthy. Finally discussing what she feels best suits her and her plans. The nurse will be evaluating Jessica’s understanding of what she has been taught and understood. From this information gathering, the nurse can then determine if the education has been successful also allowing Jessica to relay whether she is feeling her learning requirements have been met.
Nurses complying with all aspects and steps of the teaching process is important and critical for effective patient educational outcomes. Thorough knowledge of every stage is imperative to result in the patients understanding. For a detailed, thorough assessment to be precise, it must include the patient history, stage of development, physical, cognitive and psychosocial information as well as social determinants that could influence the patients’ health. With all of these components considered, the nurse can then make a factual diagnosis, cultivate a plan to address and teach required learning needs and desires, implement the teaching and finally evaluate the entire process and its outcomes.
In conclusion, if the process of teaching has not been complied with correctly, a patient may not benefit from the given education. This may possibly lead to poor outcomes, lowered self-confidence and could have a damaging impact on the patient’s general wellbeing.
- Beeken, R.J., Williams, K., Wardle,J,. & Croker,H, (2016). “What About Diet?” A Qualitative study of cancer survivors views on diet and cancer and their sources of information, doi: 10.1111/ecc.12629
- Berman, A., Kozier, B., & Erb, G, L., Kozier and Erb’s (2016), Fundamentals of Nursing: Concepts, Process and Practice. (4th ed, ). Melbourne,Australia: Pearson
- Bowman, J., Mogensen, L., Marsland, E .,& Lanin, N. (2015). The development, content validity and inter-rater reliability of the SMART-Goal Evaluation Method: A standardised method for evaluating clinical goals. Australian Occupational Therapy Journal, 62(6), doi: 10.1111/1440-1630.12218
- Burton, T. (2013). Client education. In J.cRISP, C. Taylor, C. Douglas &G. Rebeiro (Eds.), Potter & Perry’s Fundamentals of Nursing (4th ed., pp218-243). Chatswood, Australia: Elsevier Mosby.
- Flippo-Mortin, T., Walsh, K., Chambers, K., Amacker-North, L., White, B., Sarantou, T., Boselli,D., & White, R.L. (2016). Surgical Decision Making in the BRCA- Positive Population: Institutional Experience and Comparison with Recent Literature.
- Feldhusen, A, E. (2017). Breast health, Midwifery Today 44-69. https/books.google.com.au
- Grambie, K., Hancoco, K., Chang, E., Vardenega, L., Wonghongkul, T., Chanakok, A., & Mahawan, S. (2014). Breast screening at Australian and Thai worksites: A Comparison of program effectiveness, doi: 10.5172/conu.19.1-2.181
- Kaslingham, G., Ramalingam, M., & Chinnavan, E. (2014). Assessment of learning domains to improve student’s learning in higher education. Journal of Young Pharmacists, 6 (1), 27-33. doi: 10.5530/jyp.2014.1.5
- Munyaradzi, D., January, J., & Maradzika, J. ( 2014). Breast cancer screening among women of child-bearing age. Health care for women International, doi: 10.1080/07399332.2014.920843
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- Perez Rivas, F.J., Martin-Iglesias, S., Pacheco del Cerro, Jose Luis, Minguet Arenas, C., Garcia Lopez, M., & Beamud Lagos, M. (2016). Effectiveness of nursing process use in primary care. International Journal of Nursing Knowledge, 27(1), 43-48. doi:10.1111/2047-3095.12073
- Rosalinda, A, L., (1994). Applying nursing process: A step-by-step guide (3rd ed pp17), Philadelphia, PA
- Santrock, J.W. (2014). Lifespan development. North Ryde, NSW: Mc Graw Hill Education
- Seven, M., Bahar, M., Akyuz, A., & Erdogan, H., (2015). How group education impacts female factory workers behaviour and readiness to receive mammography and pap smear, doi: 10.3233/WOR- 152041
- Shackelford, J.A., Weyhenmeyer, M.A., & Mabus, L.K.(2014). Fostering Early Breast Cancer Detection: Faith Community nurses Reaching At-Risk Populations. doi:10.1188/14.cion.E113-E117
- Sodergen, S,C., Husson, O., Rohde, G.E., Tomaszewska, I.M., Griffiths, H., Pessing, A., Yarom, N., Din, A., & Darlington, A.S. (2018). Does age matter? A Comparison of health-related quality of life issues of adolescents and young adults, European Journal of Cancer Care
- Witney, C., Hendricks, J., & Cope, V. (2015). The Specialist Breast Care Nurse within an online support community: Adding the 16th moment of cancer doi: 10.20467/1091-5710-19.33
Appendix A – The Case Study
You are the registered nurse working in a Women’s health centre. Jessica is a healthy 36-year-old mother of 2 young children aged 4 and 7. Jessica has become more aware of the risk of breast cancer due to her maternal aunt’s recent diagnosis and subsequent treatment and she is seeking education regarding how she can be proactive in her health care.
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