Far Eastern University

Institute of Nursing

I. Health Education Perspective

A. Historical Development in Health Education
● Health education is an art, because it draws upon the scientific knowledge amassed in the pursuit of numerous
sciences (medicine and it’s allied sciences –biology, psychology, social sciences and many practical arts).
● The analysis (science) and synthesis (philosophy) of this knowledge constitute the materials out of which health
education of the individual and community emerges.
● Health education is dynamic and has been affected by scientific, political, social, artistic, economic, philosophical
changes of the times.

In The Earliest Civilization

● Eating the flesh of unclean animals was forbidden.
● Disease was taken as an expression of the wrath of the evil spirits and cleanliness was practiced as next to
godliness which was more for religious purposes than for hygienic purposes.

Ancient Greek
● Hygeia, which means Health, the legendary daughter of Aesculapius, the God of Healing became Goddess of
Health.
General assumption:
● Healers knew enough and that a man who adhered to hygienic modes of life, can attain long life.
● The Greeks were interested in their day by day health and was evidenced by writings such as:
a. Hippocratic Corpus (Hippocratic Canon) which is some 70 Alexandrian-era Greek books
on subjects concerning medicine
b. Aphorisms which touched on topics within the purview and experience of the common man
Example of Aphorism: “ those who are attacked by tetanus either die in 4 days, or if they survived,
recover.”
Regimen in Health:
“A work of 2,000 words giving an outline of the main rules for eating and drinking either to get fat or
to become thin.
Child care:
“ Infants should be washed in warm water for a long time and be given to drink their wine well diluted and not
altogether cold.”
● There were instructions for personal hygiene.
● The Greek education played a part in the dissemination of knowledge but it was addressed to the small
upper class.
● Gymnastic exercises were emphasized which included instruction on the care of the body.
To the Greeks:
● Health is a state of being in which the various forces constituting the human body were perfectly balanced.
2nd meeting WED
Romans:
● Attitude towards medicine differed from the Greeks. From the time of Cato the Censor, a knowledge of medicine
was regarded as one of the constituents of the Roman country gentlemen and Roman military forces.
● Cato the Censor, (BC 234-149), practiced medicine under the guidance of a commentarium or a medical cookbook
which contained a large range of prescriptions.
● Cornelius Celsus whose treatise De Medicina set out pharmacopeia, rules for dealing with wounds and injuries,
guidance on bathing, diet, drinking, exercise and discuss diagnosis and treatment of many of the major
diseases.
Book I – Diet, hygiene, and the benefits of exercise.
Book II – The cause of disease, its symptoms and prognosis.
Book III – Treatment of diseases, including the common cold and pneumonia
Book IV – Anatomical descriptions of selected diseases.
Book V – Medicines, including opiates, diuretics, purgatives and laxatives
Book VI – Ulcers, skin lesions and diseases
Book VII – Classical operations, such as lithotomy and removal of cataracts
Book VIII – Treatment of dislocations and fractures.

● One great masterpiece of the second century A.D. which had an influence even after the Renaissance was
Claudius Galen’s Hygeia where he gives a regimen for the young and the old.

In the Middle ages or the Dark Ages

● Man’s preoccupation was the salvation of soul rather than health for the body. It was because of this emphasis on
the soul that Christianity has made its contribution in the sphere of mental health.
● Today, the importance of personality is recognized, the need for love in interpersonal relationship to whatever
 degree and whatever form of love may be expressed.
● The Christian doctrine holds that interpersonal relationships should be regulated by law.
● While the Medieval man was preoccupied with the salvation of his soul, he had also the conviction that by means of
correct regimen, one could complete the allotted life span of three scores and ten
● This need gave rise to the literature on the preservation of health.
● The best known of this is Salernitan Regimen of Health (Regimen Sanitantis Salernitanum) and these were gobbled
up by the* bourgeois, the *burghers and *artisans.
Bourgeois - middle class, capitalist class
Burghers - conventional middle class citizen
Artisans - trained craftsman
A Salernitan Regimen of Health
Must ● If you want to be healthy, if you want to remain sound, 
Take away your heavy cares, and refrain
from anger, Be sparing of undiluted wine, eat little, get up,
After eating fine food, avoid
afternoon naps, 
Do not retain your urine nor tightly compress your anus. 
Do these things
well, and you shall live a long time.
HE ● Should you need physicians, these three doctors will suffice: A joyful mind, rest and a moderate
diet.
Routine ● In the morning, upon rising, wash your hands and face with cold water; 
Move around awhile and
stretch your limbs; 
Comb your hair and brush your teeth. These things relax your brain and
other parts of your body. After your bath keep warm; stand or walk around after a meal; go
slowly if you are of cool temperament
Practice ● Take a short afternoon nap, or none at all, as 
fever, indolence, headache and chest cold may
result from that nap.

Renaissance (1500-1750)
● Characterized by great scientific outburst and gradual release from traditionalism.
● The period where public health was developed.
● All society was awakened and a new relationship arose between the elite and anonymous mass.

Factors that contributed to the foundations of Health Education

Rise of MC ● The rise of middle class
State Growth● Growth of the state
^ technology ● Technological progress
^ --- Sciences● Growth and spread of sciences in various fields
^ Educ ● Rise of universities and seats of learning
^ Lit. ● Growth of literature and the writings of philosophers like Bacon and Rene Descartes

Francis Bacon, 1st Viscount St Alban(s)

● an English Philosopher, statesman, scientist, jurist and author. He served both as Attorney General
and Lord Chancellor of England. Although his political career ended in disgrace, he remained
extremely influential through his works, especially as philosophical advocate and practitioner of the
scientific method during the scientific revolution.

René Descartes
● A French philosopher, mathematician, and writer who spent most of his adult life in the Dutch
Republic. He has been dubbed the “Father of Modern Philosophy”, and much subsequent Western
philosophy is a response to his writings, which are studied closely to this day.
● There was increasing use of the experimental method with such men like Vesalius, Harvey,
Fracastoro, and others and their increasing tendency to individualize disease entities on the basis of
clinical observation.
● The possibility of applying scientific knowledge to the needs of the community was given
ideological form.

Andreas Vesalius
● a Flemish anatomist, physician, and author of one of the most influential books on human anatomy,
De humani corporis fabrica (On the Structure of the Human Body). Vesalius is often referred to as the
founder of modern human anatomy. Vesalius is the Latinized form of Andries van Wesel. He is
sometimes also referred to as Andreas Vesal, André Vesalio and Andre Vesale.

Girolamo Fracastoro
● an Italian physician, poet, and scholar in mathematics, geography and astronomy. Fracastoro
subscribed to the philosophy of atomism, and rejected appeals to hidden causes in scientific
investigation.
● Culture became more widely diffused because of the invention of printing, visual media (calendar), thus
culture was spread by word of mouth.
● The *Charlatans served as a medium of dissemination for they had to learn how to describe the nature of
disease, the danger of poisoning and the power of their herbs in order to sell their wares.
 Charlatan
● A person who pretends to have a knowledge or skill that he does not possess especially medical
knowledge.

Age of Enlightenment and Reason (1750-1830)

● extension of the scientific advances of the previous century.
● There was acceptance of the supreme value of intelligence and recognition that social progress could be
made effective only when there was informed public opinion.
● The new health education movement was international in character, where everywhere the same appeal to
reason coupled in belief in progress and perfectibility – thus the ascent of man from barbarism to
civilization
● Health Education movement was influenced by three groups of men:
1. Legislators & social workers (Howard, Pestalozzi and Florence Nightingale ), who created,
promoted, and enforced new social and public Health laws
2. Medical men ( Jenner, Frank, Chadwick, Pasteur, Lister and Koch) who discovered new methods
of disease prevention, created preventive medicine and applied and spread the knowledge
of new public health measures.

Louis Pasteur
● a French chemist and microbiologist born in Dole. He is remembered for his remarkable
breakthroughs in the causes and preventions of diseases. His discoveries reduced mortality from
puerperal fever, and he created the first vaccines for rabies and anthrax. His experiments supported
the germ theory of disease. He was best known to the general public for inventing a method to stop
milk and wine from causing sickness, a process that came to be called pasteurization. He is
regarded as one of the three main founders of microbiology, together with Ferdinand Cohn and
Robert Koch.

Heinrich Hermann Robert Koch

● a German physician. He became famous for isolating Bacillus anthracis (1877), the Tuberculosis
bacillus (1882) and Vibrio cholerae (1883) and for his development of Koch's postulates.[1]He was
awarded the Nobel Prize in Physiology or Medicine in 1905 for his tuberculosis findings. He is
considered one of the founders of microbiology.

3. Writers such as Rosseau, Dickens, Hugo, Stowe who portrayed social conditions and aroused
public opinion and created demand for legislation.

Characteristics of health education during the earlier periods:

1. It was based on authority and tradition – its sources were the classical, medical authors, empirical
knowledge and folklore.
2. It was closely linked to literacy of the people – as more people learned to read, more health literature was
produced for them.
3. The audience for health literature was affected by the rise of new social and political orders like the middle
class – books, manuals and articles in periodicals on child rearing were read for guidance by both the
upper and middle class parents as well as the working class parents.
4. Health education was directed to the individual and was not concerned with the community except when the
need arises in times of epidemics.

18th Century
● There was an endeavor to project hygiene from personal to public plane.
● Illustrated by the investigations of John Howard in which he laid bare the appealing condition in the English
prisons
● Through resolutions of the connection between jail and jail fevers. John Howard aroused public opinion.
He showed that people are galvanized into actions when facts about social diseases are made
available to them and that an aroused and informed public opinion could lever social reform.
19th Century
Requirements for Health Education:
● purpose to drive it forward – purpose was powered by self -interest: eg. Cholera and
Industrialization.
● Knowledge to make it effective – HE leaped forward from the darkness of the middle ages to
scientific outlook of the modern world.
● Means to get it across – handbills, councils local boards, books were increased.

Results
● Increase in Health educators: physicians, nurses, midwives and sanitarians
● Modern Public Health developed

20th Century
 ● Health education gained full impetus
● Objective of Health education was changed
● It is not enough simply to present information: what counts is whether and how knowledge is applied
● Community is an organized structure
3rd meeting FRI ● HE is concerned ultimately with the process of social changes

PHILIPPINES
Periods with no sharp demarcation
1. MYTHICAL – characterized by a fatalistic attitude to disease.
● Bathala was the supreme being and to appease him, offerings were coursed through the
anitos or the katalonan who was a priestess and a physician in the community
● Fatalistic - belief that all events are predetermined and therefore inevitable
● Anitos – goddess of wild tribes
Anito (or Anitu) is the collective name for Pre-Hispanic belief system that exist in
the Philippines. It is also the name for spirits, which may include deceased
ancestors and nature-spirits or diwatas. Native Filipinos usually keep statues to
represent these spirits and to ask guidance and even magical protection.
● Superstitions – epidemics were considered scourges from heaven and this period gave
birth to the “mangkukulam”, who could be countered by the “anting-anting”
● Empirical – disease could be altered by medicinal plants and some of these men became
skilled in the art of healing with herbs. Gave rise to “herbolarios” disseminators of
health information
● Scientific – based on an organized body of knowledge

2. SPANISH ERA
● Hospitals were the medium for health education, first of which was San Juan de Dios
Hospital established in 1577. Followed by San Lazaro Hospital Hence, it can be
said that the religious orders, who organized these hospitals were the first health
educators.
● During epidemics, to protect the general population, ordinances, decrees, instructions
and proclamations, were issued and these were disseminated to the general
population thru “bandilos,” newspapers and billboards.

3. SCIENTIFIC PERIOD
● Dr. Francisco Xavier de Balmis:
● introduced vaccination against small pox in 1805 and also served as a form of health
education.

Health education was carried out thru the following programs:

Food inspection
Food production
Communicable disease control
Provision of water supply
Measures to aid sufferers of public calamities.

4. AMERICAN PERIOD
● Systematic and organized health education movement coincident with the establishment
of public school system.
● 1904 – school health service was instituted – inspection of school children and of
premises, and provision of medical and dental services
● Voluntary agencies: PNRC,PTB Society, Gota de Leche
● 1950 – the first health educator was employed in the health department.
● 1952 – 5-year health education program was developed in the Department of Health
● 1956 – Institute of Hygiene, UP, included in its curriculum professional training
in health education.

Historical Foundations for Patient Education in Health Care

Patient education has long been a common intervention used in health care.

Three phases in the development of organized health care

Not included in my notes

• First phase
o Mid-1800s to the turn of the 20th century
o Emergence of nursing and other health professions
o Technological developments
o Spread of communicable diseases
o Growing interest in the welfare of mothers and children
o Florence Nightingale’s Health Teaching in Towns and Villages
 • Second phase
o First four decades of the 20th century
Not included in my notes
o Division of Child Hygiene established
o Diagnostic tools, scientific discoveries, new vaccines and antibiotic medications, and effective
surgery and treatment practices
o National League of Nursing Education (NLNE) recognized that public health nurses were essential.
• Third phase
o Began after World War II
o Significant scientific accomplishments
o Profound changes in health care delivery
o Mid-1960s, health care became a right and not a privilege for all Americans
o Titles XVIII and XIX of the Social Security Act and the creation of Medicare and Medicaid
o American Public Health Association formed the Committee on Educational Tasks in Chronic Illness
in 1968.
o Developed a model that defined the educational processes necessary for patient and family
education
o President Nixon and the concept of patient education
o Department of Health, Education, and Welfare
o American Hospital Association’s Statement on a Patient’s Bill of Rights
o Outlines patients’ rights to receive current information about their diagnosis, treatment, and
prognosis
o Guarantees a patient’s right to respectful and considerate care
o The Joint Commission’s Accreditation Manual for Hospitals
o Broadened the scope of patient education and specified that criteria for patient education be
established
o Healthy People 2000, Healthy People 2010, and Health People 2020 established educational and
community-based programs.
o Published a broad set of competencies for the 21st century
o Many competencies focus on the teaching role of health professionals.
o Role of the nurse as educator has evolved from a disease-oriented approach to a more prevention-
oriented approach.
o Emphasis now on empowering patients to use their potentials, abilities, and resources to the fullest

B. ISSUES AND TRENDS IN HEALTH EDUCATION

1. Healthy People 2010: Understanding and Improving Health
● A document that put forth national health goals and objectives for the future.
● A national health promotion and disease prevention initiative.
2. Healthy People 2020: Focuses on the Determinants of Health
● A renewed focus on identifying, measuring, tracking, and reducing health disparities through determinants of
health approach.
Vision: A society in which all people live long, healthy lives.
Mission: Healthy People 2020 strives to:
● Identify nationwide health improvement priorities.
● Increase public awareness and understanding of the determinants of health, disease, and disability
and the opportunities for progress.
● Provide measurable objectives and goals that are applicable at the national, State, and local levels.
● Engage multiple sectors to take actions to strengthen policies and improve practices that are
driven by the best available evidence and knowledge.
● Identify critical research, evaluation, and data collection needs.
Goals
● Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
● Achieve health equity, eliminate disparities, and improve the health of all groups.
● Create social and physical environments that promote good health for all.
● Promote quality of life, healthy development, and healthy behaviors across all life stages.
Four foundation health measures will serve as an indicator of progress towards achieving these
goals:
1. General Health Status
2. Health-Related Quality of Life and Well-Being
3. Determinants of Health
4. Disparities

Topic areas for 2020:

Blood Disorders and Blood Dyscracias Adolescent Health
Safety Dementias, Including Alzheimer’s Disease Genomics
Early and Middle Childhood Global Health
Healthcare-Associated Infections Older Adults
Health-Related Quality of Life and Well-Being Preparedness
Lesbian, Gay, Bisexual, and Transgender Health Sleep Health
Social Determinants of Health
 (cont. Issues and trends in HE)

3. The growth of managed care has resulted in shifts in reimbursement for healthcare services.
4. Health providers are recognizing the economic and social values of reaching out to communities, school, and
workplaces to provide education for disease prevention and health promotion
5. Politicians and healthcare administrators alike recognize the importance of health education to accomplish the
economic goal of reducing the high cost of health services.
6. Healthcare professionals are increasingly concerned about malpractice claims and disciplinary actions for
incompetence.
7. Nurses continue to define their professional role, body of knowledge, scope of practice, and expertise, with client
education as central to the practice of nursing
8. Consumers are demanding increased knowledge and skills about how to care for themselves and how to prevent
disease.
9. Demographic trends, particularly the aging population, are requiring an emphasis to be placed on self-reliance and
maintenance of healthy status over extended lifespan.
10. Among the major causes of morbidity and mortality are those diseases now recognized as being lifestyle-related
and preventable through educational intervention.
11. The increase in chronic and incurable conditions requires that individuals and families become informed
participants to manage their own illnesses.
12. Advanced technology is increasing the complexity of care and treatment in home and community-based settings.
13. Health care providers are becoming increasingly aware that client health literacy is an essential skill if health
outcomes are to be improved nationwide.
14. There is a belief on the part of nurses and other healthcare providers, which is supported by research, that client
education improves compliance and, hence, health and well- being.
15. An increasing number of self-help group exist to support clients in meeting their physical and psychosocial needs.
16. The Aquino Health Agenda: Universal Health Care for All Filipinos Universal Health Care is a vision and a
strategy: A Vision of how things ought to be, meaning

1) Filipinos are healthy, free from disease & infirmity;

2) Filipinos have access to quality health services

As a strategy, it is how the DOH will strive to :

• a. achieve better health outcomes

• b. make the health system more responsive
• c. reduce the inequities in health created by the widening gap between the rich and the poor.

♦ Simply put, universal health care prioritizes the needs of millions and millions of poor Filipino families which comprise majority
of our population.

♦ We intend to focus our energies on the poorest two fifths or lowest two quintiles of our population.

♦ MDG Targets in 2000, the Philippines, along with 188 other countries signed the UN Millennium Declaration.

♦ This declaration seeks to decisively fight hunger, disease and poverty and foster development in the developing world

♦ This pledge was translated into 8 Millennium Development Goals, which are specific, concrete, time-bound and
quantitative targets for action by 2015 and was later developed into 17 Sustainable Development Goals (SDG).

17. Duterte Health Agenda/ Phillipine Health Agenda 2016-2022: All for Health towards Health for ALL
(Lahat para sa Kalusugan tungo sa Kalusugan para sa lahat )
The new health system aims for:
1. Financial protection 1. No poverty
2. Zero Hunger
2. Better health outcomes 3. Good health & well-being
3. Responsiveness 4. Quality Education
5. Gender Equality
This will be attainable through A C H I E V E 6. Clean water and sanitation
7. Affordable and clean energy
A- Advance health promotion, primary care and quality 8. Decent work and economic growth
9. Industry, Innovation and Infrastructure
C- Cover all Filipinos against financial health risk 10. Reduced Inequalities
H- Harness the power of HRH 11. Sustainable cities & communities
12. Responsible consumption and production
I- Invest in eHealth and data for decision-making 13. Climate action
E- Enforce standards, accountability and transparency 14. Life below water
V- Value clients and patients 15. Life on land
16. Peace and justice strong institutions
E- Elicit multi-stakeholder support for health 17. Partnership for the goals

Guarantees:

1. All life stages and triple burden of disease ( Services for both the well and the sick)
2. Service delivery network ( Functional Network of Health facilities)
3. Universal Health Insurance ( Financial Freedom when Accessing Services)
THEORIES IN HEALTH EDUCATION
1. PENDER’S HEALTH PROMOTION THEORY
● Developed originally by Nola J. Pender in in 1982 and was proposed as a holistic predictive model of Health –
promoting behavior for use in research and practice. It was revised in 1996.
● Professor Emeritus in the School of Nursing at the University of Michigan, and an advocate of health promotion.
● Health Promotion and Disease Prevention should be the primary focus in health care, and when health promotion
and prevention fail to prevent problems, then care in illness becomes the next priority.

Defined 2 concepts:
Health promotion is defined as behavior motivated by the desire to increase well-being and actualize human health
potential. It is an approach to wellness.
Health protection or illness prevention is described as behavior motivated by the desire to actively avoid illness,
detect it early, or maintain functioning within the constraints of illness. (Kozier, 2004)

Sequence of major components and variables:

A. Individual characteristics and experiences (prior related behavior and personal factors)
B. Behavior-specific cognitions and affect (perceived benefits of action, perceived barriers to action, perceived self-
efficacy, activity-related affect, interpersonal influences, and situational influences).
C. Behavioral outcomes (commitment to a plan of action, immediate competing demands and preferences, and health-
promoting behavior).

PENDER’S HEALTH PROMOTION THEORY

Sequence of major components and variables:

1. INDIVIDUAL CHARACTERISTICS AND EXPERIENCES
▪ Prior related behavior
▪ Personal factor
Biological factors
▪ include variables such as age, gender, body mass index, pubertal status, aerobic capacity,
strength, agility, or balance.
Psychological factors
▪ include variables such as self-esteem, self-motivation, personal competence, perceived health
status and definition of health.
Socio-cultural factors
▪ Include variables such as race, ethnicity, acculturation, education and socio-economic status.

2. BEHAVIOR SPECIFIC-COGNITION AND AFFECT

a. Perceived benefits of action
▪ Anticipated positive outcomes that will occur from health behaviour.
b. Perceived barriers to action
▪ Anticipated, imagined or real blocks and personal costs of understanding a given behaviour
 c. Perceived self-efficacy
▪ Judgement of personal capability to organize and execute a health-promoting behavior.
▪ Perceived self-efficacy influences perceived barriers to action so higher efficacy result in lowered
perceptions of barriers to the performance of the behavior
d. Activity-related affect
▪ Subjective positive or negative feeling that occur before, during and following behavior based on the stimulus
properties of the behaviour itself.
▪ Activity-related affect influences perceived self-efficacy, which means the more positive the subjective
feeling, the greater the feeling of efficacy. In turn, increased feelings of efficacy can generate positive affect.
e. Influences
▪ Cognition concerning behaviours, beliefs, or attitudes of the others.
e.1. Interpersonal influences include: norms (expectations of significant others), social support (instrumental
and emotional encouragement) and modeling (vicarious learning through observing others engaged
in a particular behaviour).
▪ Primary sources of interpersonal influences are families, peers, and healthcare providers.
e.2. Situational influences
▪ Personal perceptions and cognitions of any given situation or context that can facilitate or impede
behaviour.
▪ Include perceptions of options available, demand characteristics and aesthetic features of the
environment in which given health promoting is proposed to take place.
▪ Situational influences may have direct or indirect influences on health behaviour.
3. BEHAVIORAL OUTCOME
3.1. Commitment to Plan Of Action
▪ The concept of intention and identification of a planned strategy leads to implementation of health behavior
3.2. Immediate Competing Demands and Preferences
▪ Competing demands are those alternative behaviors over which individuals have low control because there
are environmental contingencies such as work or family care responsibilities
3.3. Competing preferences
▪ Competing preferences are alternative behaviors over which individuals exert relatively high control, such as
choice of ice cream or apple for a snack

▪ This model is moving towards understanding multi-faceted nature of persons correlating with their interpersonal nature and
interacting with their interpersonal & physical environments as they trail towards health.
▪ Because of the model, nurses have already advanced their health approaches, addressing not only the curative side, but as
well as prevention of diseases & promotion of well-being. Application of this theory is varied and substantive on its own.

2. ASSUMPTIONS OF THE HEALTH PROMOTION MODEL

1. Individuals seek to actively regulate their own behavior.
2. Individuals in all their biopsychosocial complexity interact with the environment, progressively
transforming the environment and being transformed over time.
3. Health professionals constitute a part of the interpersonal environment, which exerts influence on persons
throughout their life span.
4. Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change.

THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL

▪ Theoretical statements derived from the model provide a basis for investigative work on health behaviors.
▪ The HPM is based on the following theoretical propositions:
1. Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting
behavior.
2. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.
3. Perceived barriers can constrain commitment to action, a mediator of behavior as well as actual behavior.
4. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action
and actual performance of the behavior.
5. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.
6. Positive affect toward a behavior results in greater perceived self-efficacy, which can in turn, result in increased
positive affect.
7. When positive emotions or affect are associated with a behavior, the probability of commitment and action is
increased.
8. Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the
behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.
9. Families, peers, and health care providers are important sources of interpersonal influence that can increase or
decrease commitment to and engagement in health-promoting behavior.
10. Situational influences in the external environment can increase or decrease commitment to or participation in
health-promoting behavior.
11. The greater the commitments to a specific plan of action, the more likely health-promoting behaviors are to be
maintained over time.
12. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which
persons have little control require immediate attention.
 13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive
and thus preferred over the target behavior.
14. Persons can modify cognitions, affect, and the interpersonal and physical environment to create incentives for
health actions.

▪ Nursing Practice “We are moving toward an era of science-based practice in nursing that incorporates the latest
findings from the behavioral and biological sciences into practice to assist people of varying cultural
backgrounds to adopt healthy lifestyles.” – Pender
▪ The health promotion model notes that each person has unique personal characteristics and experiences that affect
subsequent actions.
▪ The set of variables for behavioral specific knowledge and affect have important motivational significance.
▪ These variables can be modified through nursing actions. Health promoting behavior is the desired behavioral
outcome and is the end point in the HPM. Health promoting behaviors should result in improved health,
enhanced functional ability and better quality of life at all stages of development.
▪ The final behavioral demand is also influenced by the immediate competing demand and preferences, which can
derail an intended health promoting actions.
4th meeting MON
start notes here
3. BANDURA’S SELF EFFICACY THEORY
▪ Self-efficacy theory was originated from Social Cognitive theory by Alberto Bendura.
▪ Bandura’s Social Cognitive Model says that there are 3 factors that influence self-efficacy:
a. Behaviors
b. Environment
c. Personal / Cognitive factors

▪ According to Bandura, a person’s attitudes, abilities, and cognitive skills comprise what is known as the self-system.
▪ This system plays a major role in how we perceive situations and how we behave in response to different situations.
▪ According to Albert Bandura, self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action
required to manage prospective situations.”
▪ In other words, self-efficacy is a person’s belief in his or her ability to succeed in a particular situation.
▪ Bandura described these beliefs as determinants of how people think, behave, and feel (1994).

Four Major Sources of Self-Efficacy

1. Enactive mastery perf. outcomes
▪ Experiences that provide feedback on learners’ own capabilities
▪ Performing a task successfully strengthens sense of self-efficacy. However, failing to adequately deal with a task or
challenge can undermine and weaken self-efficacy.
2. Vicarious experiences self modeling
▪ Those that provide comparative information about the attainments of others such as observing successful expected
behavior through the modeling of others.
▪ Social Modeling - witnessing other people successfully completing a task
3. Verbal persuasion verbal encouragement
▪ Provides the learner with information about what others believe he or she is capable of doing
▪ People could be persuaded to believe that they have the skills and capabilities to succeed.
▪ Getting verbal encouragement from others helps people overcome self-doubt and instead focus on giving their best
effort to the task at hand and behavior.
4. Physiological states and internal feelings by which learners judge their ability to engage in the task at hand”
emotional state a. Emotional arousal through self-judgment of physiological states of distress
b. Psychological Responses
▪ One’s own responses and emotional reactions to situations
 ▪ Moods, emotional states, physical reactions, and stress levels can all impact how a person feels about their
personal abilities in a particular situation.
Example:
▪ A person who becomes extremely nervous before speaking in public may develop a weak sense of
self-efficacy in these situations. However, Bandura also notes "it is not the sheer intensity of
emotional and physical reactions that is important but rather how they are perceived and
interpreted" (1994).
▪ By learning how to minimize stress and elevate mood when facing difficult or challenging tasks,
people can improve their sense of self-efficacy.

4. HEALTH BELIEF MODEL

▪ The Health Belief Model was developed in the 1950s by social psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum, S.
Stephen Kegeles, and Howard Leventhal at the U.S. Public Health Service to better understand the widespread failure of
screening programs for tuberculosis.
▪ The health belief model has been applied to predict a wide variety of health-related behaviors such as being screened for the
early detection of asymptomatic diseases and receiving immunizations.
▪ More recently, the model has been applied to understand patients' responses to symptoms of disease, compliance with
medical regimens, lifestyle behaviors (e.g., sexual risk behaviors), and behaviors related to chronic illnesses, which
may require long-term behavior maintenance in addition to initial behavior change.
▪ The health belief model has been used to develop effective interventions to change health
- Modified by Becker et al in 1974 to address compliance to therapeutic regimen related behaviors by targeting various aspects
of the model's key constructs.

Two major premises on which the model is built:

1. Eventual success of disease prevention and curing regimens that involves the client’s willingness to participate
2. Belief that health is highly valued

The major interacting components and its sub components:

1. Individual Perception
a. Perceived Barriers to preventive action
▪ refer to an individual's assessment of the obstacles to behavior change.
▪ Even if an individual perceives a health condition as threatening and believes that a particular action will
effectively reduce the threat, barriers may prevent engagement in the health-promoting behavior.
▪ In other words, the perceived benefits must outweigh the perceived barriers in order for behavior change to
occur.
▪ Perceived barriers to taking action include the perceived inconvenience, expense, danger (e.g., side effects
of a medical procedure) and discomfort (e.g., pain, emotional upset) involved in engaging in the
behavior.
▪ For instance, lack of access to affordable health care and the perception that a flu vaccine shot will cause
significant pain may act as barriers to receiving the flu vaccine.
b. Cues to Action
▪ Cues to action can be internal or external. Physiological cues (e.g., pain, symptoms) are an example of
internal cues to action. External cues include events or information from close others, the media, or
health care providers promoting engagement in health-related behaviors.
▪ Examples of cues to action include a reminder postcard from a dentist, the illness of a friend or family
member, and product health warning labels. The intensity of cues needed to prompt action varies
between individuals by perceived susceptibility, seriousness, benefits, and barriers.
▪ For example, individuals who believe they are at high risk for a serious illness and who have an established
relationship with a primary care doctor may be easily persuaded to get screened for the illness after
seeing a public service announcement, whereas individuals who believe they are at low risk for the
same illness and also do not have reliable access to health care may require more intense external
cues in order to get screened.
 c. Self-Efficacy
▪ refers to an individual's perception of his or her competence to successfully perform a behavior. Self-efficacy
was added to the health belief model in an attempt to better explain individual differences in health
behaviors. The model was originally developed in order to explain engagement in one-time health-
related behaviors such as being screened for cancer or receiving an immunization.
▪ Eventually, the health belief model was applied to more substantial, long-term behavior change such as diet
modification, exercise, and smoking. Developers of the model recognized that confidence in one's
ability to effect change in outcomes (i.e., self-efficacy) was a key component of health behavior
change
d. Perceived Threat
▪ The combination of perceived seriousness and perceived susceptibility is referred to as perceived threat.
▪ Perceived seriousness and perceived susceptibility to a given health condition depend on knowledge about
the condition.
▪ The health belief model predicts that higher perceived threat leads to higher likelihood of engagement in
health-promoting behaviors.
e. Perceived benefits of preventive action
▪ refer to an individual's assessment of the value or efficacy of engaging in a health-promoting behavior to
decrease risk of disease.
▪ If an individual believes that a particular action will reduce susceptibility to a health problem or decrease its
seriousness, then he or she is likely to engage in that behavior regardless of objective facts
regarding the effectiveness of the action.
▪ For example, individuals who believe that wearing sunscreen prevents skin cancer are more likely to wear
sunscreen than individuals who believe that wearing sunscreen will not prevent the occurrence of
skin cancer.

2. Modifying Factors
▪ Individual characteristics, including demographic, psychosocial, and structural variables, can affect perceptions (i.e.,
perceived seriousness, susceptibility, benefits, and barriers) of health-related behaviors.
▪ Demographic variables include age, sex, race, ethnicity, and education, among others.
▪ Psychosocial variables include personality, social class, and peer and reference group pressure, among others.
▪ Structural variables include knowledge about a given disease and prior contact with the disease, among other
factors.
▪ The health belief model suggests that modifying variables affect health-related behaviors indirectly by affecting
perceived seriousness, susceptibility, benefits, and barriers.
a. Demographic variables
b. Sociopsychological variables
c. Structural variables

a. Perceived Susceptibility
▪ refers to subjective assessment of risk of developing a health problem.
▪ The health belief model predicts that individuals who perceive that they are susceptible to a particular health
problem will engage in behaviors to reduce their risk of developing the health problem.
▪ Individuals with low perceived susceptibility may deny that they are at risk for contracting a particular illness.
Others may acknowledge the possibility that they could develop the illness, but believe it is unlikely.
Individuals who believe they are at low risk of developing an illness are more likely to engage in
unhealthy, or risky, behaviors. Individuals who perceive a high risk that they will be personally
affected by a particular health problem are more likely to engage in behaviors to decrease their risk
of developing the condition.

b. Perceived Severity of a specific disease

▪ refers to subjective assessment of the severity of a health problem and its potential consequences.
▪ The health belief model proposes that individuals who perceive a given health problem as serious are more
likely to engage in behaviors to prevent the health problem from occurring (or reduce its severity).
▪ Perceived seriousness encompasses beliefs about the disease itself (e.g. whether it is life-threatening or
may cause disability or pain) as well as broader impacts of the disease on functioning in work and
social roles.
▪ For instance, an individual may perceive that influenza is not medically serious, but if he or she perceives
that there would be serious financial consequences as a result of being absent from work for several
days, then he or she may perceive influenza to be a particularly serious condition.

3. Likelihood of action
 Health-Promoting Behavior (i.e., increasing perceived benefits and decreasing perceived barriers)
5. GREEN’S PRECEDE-PROCEED MODEL

▪ This framework was developed by Lawrence Green and his colleagues in 1968.
▪ It is a comprehensive structure for systematic planning process of health education programs.
▪ The second edition was released in collaboration with Marshall Krueter where they have expanded the environmental, policy
and organizational factors in launching programs.
▪ Assumes that health education is dependent on voluntary active participation of the client.

▪ The PRECEDE-PROCEED model provides a comprehensive structure for assessing health and quality-of-life needs and for
designing, implementing, and evaluating health promotion and other public health programs to meet those needs.

PRECEDE
▪ (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation)
▪ outlines a diagnostic planning process to assist in the development of targeted and focused public health programs.
PROCEED
▪ (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development)
▪ guides the implementation and evaluation of the programs designed using PRECEDE.
▪ Its multidimensional approach identifies the different causation of health behavior and directs the goals and
objectives of the PROCEED since a program may be limited to addressing limited determinants of the quality of life.
PRECEDE Involves 5 Phases:
Phase 1 - Social Diagnosis Assessment on people of the community
Phase 2 - Epidemiological Diagnosis Identifying susceptible threats (diseases)
Phase 3 - Behavioral & Environmental Diagnosis
Phase 4 - Education & Organizational Diagnosis Knowledge
Phase 5 - Administrative & Policy Diagnosis

Five Steps or Phases:

Phase 1– Social Diagnosis
▪ Involves determining the quality of life or social problems and needs of a given population.
▪ Assesses the client’s perception of social problems and linking them to health-related problems.
Methods used:
a. Community survey tool
b. Focused group discussions
c. Interviews
Examples:
▪ Upon admission, the client is asked about the chief complaint? And reason for seeking medical help.
▪ Upon entry of the nurse to the community, she asks the leaders in the community about their current
problems, perceived problems, and resolutions.

Phase 2 – Epidemiological Diagnosis

▪ Consists of identifying the health determinants of these problems and needs.
▪ Focuses on observed behavioral and environmental factors present that affect health status of the clients directly or
indirectly to be able to identify specific health problems.
▪ Provides basis for program development through identifying relationships between the factors and identified health
problems and prioritization of these problems
▪ Identifies the program objectives.

Functions of Epidemiological Diagnosis:

a. Establish relationships between health problems, health conditions, and quality of life
b. Set prioirities of problem to guide program development and utilization of community resources.
c. Delineate responsibilities between involved professionals, organizations, and agencies

Indicators of Health Status:

a. Mortality c. Disability e. Prevalence – existing diseases cases at a particular point in time
b. Morbidity d. Disease f. Incidence – new cases of a disease within a period of time.
Examples:
a. A health care practitioner measures blood pressure of a client
 b. A health care practitioner screens the community and takes the weight of children 0-6 years old.
Methods used:
a. Spot Mapping
b. Screening and Laboratory Diagnostics
c. Observational Checklist.

Phase 3 – Behavioral and Environmental Diagnosis

▪ Also called the risk factors
▪ Result of the assessment would be the focus of the formulation of objectives
▪ Involves analyzing the behavioral and environmental determinants of the health problems.
▪ Focuses on finding the direct cause/s of the problem both the community target population and health workers have
identified; It focuses on the topmost problem
Behavioral assessment - identifies what behaviors/lifestyles cause or strongly related to the problem/s identified
Examples:
a. Smoking c. Improper hygiene
b. Sedentary lifestyle d. Fond of junk foods & salty foods

Environmental/Non behavioral assessment – identifies someone other than the individual that cause, encourage, or
permit an unhealthy behavior
Examples:
a. Workplace hazards (Asbestos, Mercury etc) d. Age
b. Inadequate toilet facility e. Gender
c. Inadequate basic health facilities f. Genetic predisposition

Phase 4 – Education and Organizational Diagnosis

▪ Factors that predispose to, reinforce, and enable the behaviors and lifestyles are identified.
▪ Focuses on the indirect causes of the problems or the causes of the direct causes of the problem
▪ Results of these would be the basis of the sub-objectives
▪ Indirect Causes of Problems (Contributing Risk Factors)

1. Predisposing Factors
▪ This is the initial reason/cause of the behavior.
▪ It includes anything about the individual –knowledge, existing skills, and attitude, values and beliefs (except
his motivation).
2. Enabling Factors
▪ These are factors particularly things that are outside the individual except for the motivation and the absence
of skills.
▪ It includes presence or absence, accessibility, availability of a facility.
▪ This could also include laws and policies.
3. Reinforcing Factors
▪ This either rewards or punishes a behavior.
▪ It includes media, peers, and parents, the quality of manpower or service

Example for Phase 2, 3 and 4:

Problem – Hypertension
Risk Factors – Sedentary Lifestyle, Smoking, Alcohol drinking, Obesity
Predisposing Factor (Obesity) – Inadequate knowledge about effects of obesity
Enabling Factor – Unavailability of nutritious foods
Reinforcing Factor – admiration of WWE
Wrestler Big Show (who is overweight) or other actors who are obese or overweight.
Goal: Focus on the problem. Is not limited by time. Includes, the target population, the barangay and the outcome
(include the percentage). This may not reflect the exact opposite of the problem. Could also reflect a
reduction of the problem.
Example:
▪ There would be 80% reduction on the incidence of hypertension among ages 18 years and above
in Barangay Pacquiao-Hatton

Objectives: Focus on the risk factors. If there are four risk factors then there would be 4 objectives as well. This should
state the time it should be achieved unlike the goal statement
Example:
▪ There would be 90% reduction of cases of obesity among 18 years old and above in Barangay
Pacquiao-Hatton after 1 year

Sub-objectives: Focus on the contributing risk factors/ the result of educational diagnosis.
Should also state the time. Time should be set before and not after the time set in the objective.
Examples:
▪ 98% of 18 years and above will be able to have adequate knowledge about the effects of obesity
 Phase 5 – Administrative and Policy Diagnosis
▪ Involves ascertaining which health promotion, health education and/or policy-related interventions would best be
suited to encouraging the desired changes in the behaviors or environments and in the factors that support
those behaviors and environments.
▪ Includes the
a. assessment of resources,
b. budget development and allocation,
c. development of an implementation timetable, organization or personnel within programs,
d. coordination of the program with all other departments, institutional organizations and the community.

Administrative Diagnosis
▪ the analysis of policies, resources and circumstances prevailing organizational situations that could hinder or
facilitate the development of the health program.
Policy Diagnosis
▪ to assess the compatibility of program goals and objectives with those of the organization and its
administration; does it fit into the mission statements, rules and regulations?
▪ Work in this phase is specific to the context of the program and the sponsoring organization(s) and requires political
savvy as much as theoretical or empirical knowledge
▪ Informed by theories, particularly community-level theories
▪ Assess limitations and constraints
▪ Select the best combination of methods and strategies
▪ Development of organizational and resource objectives follows

PROCEED
▪ (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development)
▪ guides the implementation and evaluation of the programs designed using PRECEDE.

▪ The PROCEED was developed by the late 1980’s in response for the need of health promotion interventions to
change unhealthy behaviors.
▪ The Proceed approach deals beyond educational interventions to the social systems environments.

PROCEED Involves 4 Phases:

Phase 6 – Implementation
Phase 7 - Process Evaluation
Phase 8 - Impact Evaluation
Phase 9 - Outcome Evaluation

Phase 6 – Implementation
▪ The interventions identified in phase five are implemented.
▪ Implementation of the program
▪ The act of converting program objectives into actions through policy changes, regulation and organization
▪ Selection of methods and strategies of the intervention, for example, education &/or other resources
▪ Program begins

Phase 7 – Process Evaluation

▪ Entails process evaluation of those interventions.
▪ Measures achievement of sub-objectives
▪ Used to evaluate the process by which the program is being implemented
▪ Measurements of implementation to control, assure, or improve the quality of the program

Phase 8 – Impact Evaluation

▪ Involves evaluating the impact of the interventions on the factors supporting behavior, and on behavior itself.
▪ Measures the program effectiveness in terms of objectives
▪ Immediate observable effects of program

PHASE 9- OUTCOME EVALUATION

▪ Measures the goal of the program and beyond.
▪ Includes measuring the life-expectancy and the quality of life
▪ Long term effect of program

Malcolm Knowles
ADULT LEARNING THEORY

6 Assumptions of Andragogy
1. Self-Concept
- Self-concept is the mental image we have of ourselves.
 - Adults are actively involved in decisions that affect themselves.
2. The Role of the Learner’s Experience
- Adults bring life experiences and knowledge to learning experiences
3. Readiness to Learn
- Adults are ready to learn when they need new information to cope effectively with life situation.
4. Orientation to Learning
- Adults learning experiences should be structured around life situations.
5. Motivation to Learn
6. The Need to Know
- Adults must recognize the necessity of learning something prior to starting the process of learning.

Limitations of Knowle’s theory

• Based on observation and experience
• No valid measurement tool
• Various order of assumptions
• Adult experiences may be negative
• These assumptions can relate to children
• The impact of culture, race, gender or environment affects learning.

Day 4

Far Eastern University

Institute of Nursing

II. PERSPECTIVE ON TEACHING AND LEARNING

A. Overview of Education on Health Care

HEALTH
▪ The state of complete physical, mental, emotional and spiritual well-being and not merely the absence of disease or
infirmity (WHO)
▪ The expression of success experienced by the organism in its effort to respond adaptively to environmental changes
(Rene Dubois)
▪ a dynamic ecological resultant involving the interaction of many complex factors and conditions (Hoyman)

EDUCATION
▪ Deliberate and systematic influence exerted by the mature person upon the immature through instruction, discipline
and harmonious development of all powers of human being (physical, social, intellectual, aesthetic, and
spiritual) directed toward the final end.
▪ “Acquisition of the art of the utilization of knowledge” (Whitehead)

HEALTH EDUCATION
▪ Helping individuals and groups to better health through equipping every individual with desirable knowledge, attitude
and skills so that he can make the necessary adaptations in the face of the challenges of the ever changing
environment.
▪ Is a learning process which is concerned with changes in knowledge, feelings and behavior of people.
▪ It is an approach for teaching patients and their families to deal with past, present & future health problems.
▪ Is a process that informs, motivates, and helps people to adopt and maintain healthy practices and lifestyles,
advocates environmental changes as needed to facilitate this goal and conducts professional training.

A PROCESS
▪ Brings about changes in the knowledge and attitude of people and thereby affecting change in health practices.
▪ The sum of experiences which favorably influence habits, attitudes, knowledge relating to individuals, community and
racial health.
▪ Progressive course, series of measures or changes.

CONCEPTS OF HEALTH EDUCATION

A. Physicians point of view
▪ A means by which better understanding of the principles of healthful living is achieved.
▪ A learning process growing out of health needs, nourished by health knowledge and producing intelligent
constructive and healthful individual and community action.
▪ A means of creating opportunities for the people to participate and assume responsibility for the solution of
their own problems in cooperation with health specialists and educators.
▪ A cooperative task in which all people who are directly engaged in public health work could participate.
▪ It covers the combined, concerted efforts of the professional and lay persons to influence community health
habits and practices.
 B. Nurses point of view
▪ Is a means of improving the health of people by employing various methods of scientific procedures to show
the most healthful ways of living.
▪ Consists of techniques that stimulate, arouse and guide people to live healthfully.
▪ The sum of activities in which health agencies engage to influence the thinking, motivation, judgment and
action of the people of the community.
C. Sanitary Engineers point of view
▪ Is a continuous process by which the public is made aware of facts and problems about health and of its
obligation individually and collectively in the attainment of physical, mental and social well-being.
D. School Administrators & Teachers point of view
▪ A cooperative task in which all engaged in public health should directly or indirectly participate for the
betterment of the health of the people.

Aims of Health Education

1. To help people understand that health is the most valuable community asset and to help them achieve health
by their own activities and efforts
2. To develop a sense of responsibility for improvement of their health as individual members of families and
communities
3. To develop scientific knowledge, attitude, and skills on health matters to enable people to develop correct habits
4. To develop ways and means of effecting favorable changes in health habits and attitudes of the people.
5. To educate people for proper use of health services in whatever form it is made available to them by the
government
6. To alter behavior which may directly or indirectly influenced occurrence or spread of diseases in a given cultural
setting
7. To help people achieve health by their own actions and efforts.
8. To promote the greater possible fulfillment of inherited powers of the body and the mind, and happy adjustment
of an individual to society
9. To provide the person with appropriate knowledge to enjoy descent health and also the knowledge of the
occurrence and spread of diseases. Thus, enabling him to adopt relevant preventive measures
10. To create in the person an interest in his own health and well-being
11. To create in the person an interest for the health of other members of his family, as well as those living in his
surroundings
12. To create in the person a desire to support health education programs in his area

Principles of Health Education

1. HE considers the health status of the people.
2. HE is learning.
3. HE involves motivation, experience and change in conduct and thinking.
4. HE should be recognized as a basic function of all health workers.
5. HE takes place in the home, in the school and the community.
6. HE is a cooperative effort.
7. HE meets the needs, interests and problems of the people affected.
8. HE is achieved by doing.
9. HE is a slow continuous process.
10. HE makes use of supplementary aids and devices.
11. HE utilizes community resources.
12. HE is a creative process.
13. HE helps people attain health through their own efforts.
14. HE makes careful evaluation of the planning, organization and implementation of all health education programs
and activities.
15. HE is an integral part of health programs.
16. Every member of the public health team has the responsibility in educating people.
17. It is not enough to impart information, what counts is what is done with the knowledge.

HEALTH EDUCATOR
♦ The facilitator or implementer of health education.
♦ Initiator of the process whereby people learn to improve their health attitude and habits to work together for
the improvement of health conditions of the family, community and the nation.

Traits / Qualities of a Health Educator

Efficient Good Communicator Good Listener
Creative / Resourceful Keen Observer Systematic
With sense of Humor Change Agent Tactful
Analytical Knowledgeable Open

EDUCATION PROCESS
Process
♦ progressive course, series of measures or changes.
 ♦ Is a systematic, sequential, logical, scientifically based, planned course of action.
♦ Consisting of two major interdependent operations:
1. Teaching
2. Learning
♦ Forms a continuous cycle
♦ involves 2 interdependent players:
1. Teacher
2. Learner
♦ mutually desired behavior changes
♦ Foster growth in the learner
♦ Growth in the teacher
Education Process Parallel Nursing Process
▪ Steps run parallel to nursing process but with different goals and objectives.
Nursing Process
▪ Planning and implementation of care based on assessment and diagnosis of the physical and psychosocial needs of
the patient.
Education process:
▪ Planning and implementation of teaching based on assessment and prioritization of the client’s learning needs,
readiness to learn and learning style
▪ A useful paradigm to assist nurses to organize and carry out the education process using the ASSURE model:
o Analyze the learner
o State the objectives
o Select the instructional methods and materials
o Use instructional methods and materials
o Require learner performance
o Evaluate the teaching plan and revise as necessary

HISTORICAL FOUNDATION FOR THE TEACHING ROLE OF NURSES

♦ Patient Education has been considered a major component of standard care given by nurses

1950s
♦ The NLE identified the course content in nursing school curricula to prepare nurses to assume the role as teachers
of others.
♦ Developed the first certified nurse educator (CNE) exam
♦ American Nurses Association (ANA) set forth statements on the functions, standards, and qualifications for nursing
practice, of which patient teaching is a key element.
♦ International Council of Nurses (ICN) has long endorsed the nurse’s role as educator to be essential component of
nursing care delivery.
♦ TODAY, all state nurse practice acts (NPA) include teaching within the scope of nursing practice responsibilities.
Nurses, by legal mandate are expected to provide instruction to consumers to assist them to maintain optimal
levels of wellness and manage illness.

1970s
American Hospital Association
♦ Developed the Patient’s Bill of Rights and has been adopted by hospitals nationwide.
♦ Established the guidelines to ensure that patients receive complete and current information concerning their
diagnosis, treatment and prognosis in terms they can reasonably be expected to understand.

Mid – 1800
♦ Responsibility for teaching has been recognized as an important role of nurses as caregivers.
Focus of teaching:
1. Care of the sick and on promoting the health of the well public.
2. Educating other nurses for professional practice.

Florence Nightingale
♦ Founder of modern nursing, ultimate educator
♦ Developed the first school of nursing
♦ Devoted a large portion of her life to teaching nurses, physicians and health officials about the importance of
proper conditions in the hospitals and homes to improve the health of the people. She emphasized the
importance of teaching patients of the need for adequate nutrition, fresh air, exercise, and personal hygiene to
improve their well-being.

By Early 1900s
♦ Public health nurses in the Philippines, clearly understood the significance of the role of the nurse as teacher in
preventing disease and in maintaining the health of the society. or decades, patient teaching has been an
independent nursing function.
♦ As early as 1918, the National League of Nursing Education (NLNE) in the US (now the National League for Nursing
 (NLN) observed the importance of health teaching as a function within the scope of nursing practice.
♦ Two decades later, this organization recognized nurses as agents for the promotion of health and the prevention of
illness in all settings in which they practiced.

As Early as 1993
Joint Commission formerly Joint Commission on Accreditation of Healthcare Organizations (JCAHO):
♦ Recognized the importance of patient education by nurses
♦ Established nursing standards for patient education.
♦ Those standards known as mandates described the type and level of care, treatment and services that must be
provided by an agency or organization to receive accreditation. More recently, the JC has expanded its
expectation to include an interdisciplinary team approach in the provision of patient education as well as
evidence, that patient and their significant others participate in care and decision making and understand what
they have been taught. Hence, the following must be considered by the health care providers during the
education process:
Literacy level Language skills
Educational background Culture of every client

1995
♦ PEW HEALTH PROFESSION COMMISSION (PHPC) published a broad set of competencies it believed would mark
the success of the health profession in the 21st century. In 1998, it released a fourth report on the follow-up on
health professional practice in the new millennium.

Recommendations proposed by the PHPC:

1. Provide clinically competent and coordinated care to the public
2. Involve patients and their families in the decision making process regarding health interventions
3. Provide clients with education and counseling on ethical issues
4. Expand public access to effective care
5. Ensure cost-effective and appropriate care for the consumer
6. Provide for prevention of illness and promotion of healthy lifestyle

According to Grueninger (1995) :

The transition toward wellness has entailed a progression:
“from disease-oriented patient education (DOPE)
prevention-oriented patient education (POPE)
health-oriented patient education (HOPE).”
This new approach has changed the role of the nurse:
a. From one of wise healer to expert advisor or teacher to facilitator of change.
b. Emphasis is now on empowering patients to use their potentials, abilities, and resources to the fullest
c. Another role of today’s educator is training the trainer – preparing the nursing staff through continuing
education, in-service programs, and staff development to maintain and improve their clinical skills
and teaching abilities. The key to success of the nursing profession is for the nurses to teach other
nurses.
d. Another very important role of the nurse as educator is serving as a clinical instructor for the students in the
practice setting. Staff nurses function as clinical preceptors and mentors to ensure that nursing
students meet their expected learning outcomes.

2006
♦ Institute of Healthcare Management was organized.
♦ Objective: To reduce the 15 million incidents of medical harm in US hospitals each year.
♦ Major implications: Teaching patients and their families as well as nursing staff and students ways how they can
improve care to reduce injuries, save lives, and decrease cost of health care

2007 - SULLIVAN ALLIANCE

Objective: To recruit and educate staff nurses to deliver culturally competent care to the public they serve. Effective
health care and health education of patients and their families depends on a sound scientific base and
cultural awareness in an increasingly diverse society.
Goal: To increase the racial and cultural mix of nursing faculty, students, and staff, who will be sensitive to the needs of
clients of diverse backgrounds.
♦ Since 1980s, the role of the nurse as educator has undergone a paradigm shift, evolving from what once
was a disease-oriented approach to a more prevention-oriented approach.
♦ Focus in teaching: Teaching for the promotion and maintenance of health. Education has become a part of
the discharge plan at the end of hospitalization, and has expanded to become a part of
comprehensive plan of care that occurs across the continuum for the healthcare delivery process

C. ROLES OF THE NURSE AS A HEALTH EDUCATOR

 ♦ The role of educator has shifted from traditional position of being the giver of information to that of a process designer
or coordinator.
♦ Shift from Traditional teacher-centered to learner-centered approach which requires:
a. Skill in needs assessment
b. Ability to involve learners in planning
c. Link teachers to learning resources
d. Encourage learner initiative.

Roles of the Nurse as a Health Educator in Health Promotion

1. Facilitator of Change
Goal: To promote health
The following are effective in facilitating change in the learning situation:
Analyzing Demonstrating Asking questions
Explaining Practicing Providing closure
Dividing complex skills
2. Contractor
♦ Stating mutual goals to be accomplished
♦ Devising an agreed-upon plan for action
♦ Evaluating the plan
♦ Deriving alternatives
♦ A contract involves trusting relationship
3. Organizer
♦ Manipulation of materials and space, sequential organization of content from simple to complex,
♦ Determining priority of subject matter
4. Evaluator
♦ Evaluative processes are integral part of all learning.
♦ Self-evaluation, learner evaluation, organization evaluation, peer evaluation
5. Coordinator of care.
♦ By ensuring consistency of information, nurses can support their clients in their efforts to achieve the goal of optimal
health.
♦ They also can assist their colleagues in gaining knowledge and skills necessary for the delivery of professional
nursing care.
6. Trainor of trainers

Elements of an ideal relationship:

1. Both parties have trust and respect.
2. The teacher assumes the student can learn and is sensitive to individual needs.
3. Both feel free to learn and make mistakes.

D. HALLMARKS OF EFFECTIVE TEACHING IN NURSING

Students have different opinions on the qualities of a good teacher based on their:
a. Individual learning styles
b. Goals
c. Personal needs

Six Major Categories of Effective Teaching (Jacobson, 1966)

1. Professional Competence
a. Shows genuine interest in patients and displays confidence in his/her professional abilities
b. Creative and stimulating, can excite student’s interest in nursing.
c. Polishes skills throughout his/her career through reading, research, clinical practice and continuing
education
d. Portrays excellent clinical skills and judgment becomes a positive role model for learners
e. Demonstrate clinical skills with expertise
f. A teacher who aims at excellence develops a thorough knowledge of subject matter.

2. Interpersonal relationships with students

a. taking a personal interest in learners f. being fair
b. being sensitive to their feelings and problems g. permitting learners to express differing points of view
c. conveying respect for them h. conveying a sense of warmth
d. alleviating their anxieties i. being accessible for conferences
e. creating an atmosphere in which they feel free to ask questions.

Disadvantages:
a. Maintaining a professional distance necessary when time comes to evaluate the student
b. Leads to lack of discipline in the classroom, with students taking advantage of their relationship with the
teacher.
Ways how educators help learners maintain self-esteem and minimize anxieties:
 a. Empathic listening
b. Acceptance
c. Honest communication

3. Personal Characteristics
a. Personal magnetism g. Sense of humor
b. Enthusiasm h. Good speaking voice
c. Cheerfulness i. Self-confidence
d. Self-control j. Willingness to admit errors
e. Patience k. Caring attitude
f. Flexibility

4. Teaching Practice
♦ mechanics, methods, and skills in classroom and clinical teaching.
♦ Teaching subject matter in a stimulating way and inspiring learner interest depend on several factors:
a. Teacher’s style
b. Personality
c. Personal interest in the subject
d. Use of a variety of teaching strategies.

5. Evaluation Practices valued by students:

a. clearly communicating expectations
b. providing timely feedback on student’s progress
c. correcting students tactfully
d. being fair in the evaluation process
e. giving tests that are pertinent to the subject matter

6. Availability to the students

a. giving guidance during stressful clinical situations
b. physically helping students give nursing care
c. giving appropriate amount of supervision
d. freely answering questions
e. acting as a resource person during clinical learning experiences

E. PRINCIPLES OF GOOD TEACHING PRACTICE IN UNDERGRADUATE EDUCATION

1. Encourage student-faculty contact.
2. Encourage cooperation among students.
3. Encourage active learning.
4. Give prompt feedback.
5. Emphasize time on task.
6. Communicate high expectations.
7. Respect diverse talents and ways of learning.

TEACHING
- Is sharing of knowledge and experience is usually organize within discipline

INSTRUCTION
- is just one aspect of teaching which involves communicating of information about specific skills. It is used interchangeably
with the word teaching.

LEARNING
- Is a change in behavior (KSA) that can occur at any time or in any place as a result of exposure to environmental stimuli.

PATIENT EDUCATION
- Is a process of assisting people to learn health-related behaviors which can be incorporated into their everyday lives.

One important fact when evaluating teaching effectiveness

THERE IS NO ONE STYLE, TECHNIQUE, OR SKILL THAT IS EFFECTIVE FOR ALL LEARNERS AND ALL
TEACHING SITUATIONS.

Six major categories of effective teaching (Jacobson,1966)

1. Professional Competence
2. Interpersonal relationship with the students
3. Personal characteristics
4. Teaching practices
5. Evaluation practices
6. Availability to students
1. Professional Competence
a. Shows genuine interest in patients and displays confidence in his professional abilities
b. Creative and stimulating
♦ can excite student’s interest in nursing
c. Polishes skills throughout his career
♦ through reading, research, clinical practice and continuing education
d. Portrays excellent clinical skills and judgment
♦ becomes a positive role model for learners
e. Demonstrate clinical skills with expertise
f. Aims at excellence
♦ develops a thorough knowledge of subject matter

2. Interpersonal relationships with students

a. Take personal interest in learners
b. Be sensitive to their feelings and problems
c. Convey respect for them
d. Alleviate their anxieties
e. Be accessible for conferences
f. Be fair
g. Permit learners to express differing points of view
h. Create an atmosphere where students feel free to ask questions
i. Convey a sense of warmth

Disadvantages:
1. Maintains professional distance necessary to evaluate the student
2. Leads to lack of discipline in the classroom, with students taking advantage of their relationship with the teacher

Ways how educators help learners maintain self-esteem and minimize anxieties:
1. Empathic listening
2. Acceptance
3. Honest communication

3.Personal Characteristics
a. Personal magnetism g. Enthusiasm
b. Sense of humor h. Cheerfulness
c. Good speaking voice i. Self-control
d. Caring attitude j. Patience
e. Self-confidence k. Flexibility
f. Willingness to admit errors

4. Teaching Practice
♦ Mechanics, methods, and skills in classroom and clinical teaching.
Teaching subject matter in a stimulating way and inspiring learner interest depend on several factors:
a. Teacher’s style
b. Personality
c. Personal interest in the subject
d. Use of a variety of teaching strategies

5.Evaluation Practices valued by students

a. communicates expectations clearly
b. provides timely feedback on students’ progress
c. correct students tactfully
d. being fair in the evaluation process
e. gives tests pertinent to the subject matter

6. Availability to the students

a. gives guidance during stressful clinical situations
b. physically help students give nursing care
c. gives appropriate amount of supervision
d. freely answer questions
e. act as a resource person during clinical learning experiences

F. BARRIERS TO EDUCATION AND OBSTACLES TO LEARNING

Barriers to Teaching
♦ Those factors that impede the nurse’s ability to deliver educational services.
Obstacle to Learning
♦ Those factors that negatively affect the ability of the learner to pay attention to and process information.

Barriers to Teaching:
1. Lack of time to teach
2. Nurses do not feel competent or confident with their teaching skills.
3. Personal characteristics of the nurse educator
4. Low priority assigned to patient and staff education by administration and supervisory personnel
5. Environment
 6. Absence of 3rd party reimbursement to support patient education
7. Some nurses and physicians question whether patient education is effective as means to improve health
outcomes.
8. The type of documentation system used by healthcare agencies.

Obstacles to Learning:
1. Lack of time to learn
2. The stress of acute and chronic illness, anxiety, and sensory deficits in patients
3. Low literacy and functional health illiteracy
4. Negative influence of the hospital environment resulting in:
a. Loss of control
b. Lack of privacy
c. Social isolation
5. Personal characteristics of the learner that influence the success of educational endeavors:
a. Readiness to learn
b. Motivation and compliance
c. Developmental-stage characteristics and compliance
d. Learning style
6. Extent of behavioral changes needed both in number and in complexity, can overwhelm the learners and
dissuade them from attending to and accomplishing learning objectives and goals.
7. Lack of support and lack of ongoing positive reinforcements from the nurse and significant others.
8. Denial of learning needs, resentment of authority, and lack of willingness to take responsibility.
9. Inconvenience, complexity, inaccessibility, fragmentation, and dehumanization of the health care system result in
frustration and abandonment of efforts to participate and comply with goals and objectives of learning.

References

Bastable, S.,(2019). Nurse as Educator Principles of Teaching and Learning for Nursing Practice, (5th ed.), Jones and Barlette
Publishers, Boston

Bastable, S.,(2023). Nurse as Educator Principles of Teaching and Learning for Nursing Practice, (6th ed.), Jones and Barlette
Publishers, Boston

De Young, S.,(2015). Teaching strategies for Nurse educators, (3rd ed.), Pearson Prentice Hall , Pearson education Inc., New
Jersey.