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Parents, Prospective Parents and Health Professionals
Teaching in Health Service Settings
This book is about teaching parents â and about patients learning. It is written for those health professionals, particularly in the maternity and child health services, who are concerned with teaching patients,1 and for members of voluntary organisations and consumer groups who are interested in using or improving the opportunities available for parents to learn through contact with health service staff. It is not, however, either a manual of tips for health service teachers,2 or a handbook for articulate consumers on how to beat the system.3 Instead, this book consists of a series of studies of health service teaching in particular settings, in labour wards, antenatal classes and clinics, and by particular methods, through group work, through individual interviews, through in-patient care, and also indirectly, through leaflets. These settings, and these methods, have built-in strengths and weaknesses. Staff who teach, and parents who wish, as patients, to learn, could usefully take account of these strengths and weaknesses, so that they can together make the fullest use of the opportunities available in these settings, without making demands on them which are unrealistic.
The settings chosen for examination feature particular groups of practitioners: mid wives, health visitors,4 physiotherapists, doctors, and the writers of health educational literature. They also show members of a particular voluntary organisation, the National Childbirth Trust, both as providers and consumers of teaching. The NCT provides antenatal classes and educational literature to a small proportion of expectant parents, and in some parts of the country also provides advice on breast feeding and friendly postnatal support. These professional and voluntary groups have been chosen for study because they have a clearly stated and established interest in teaching as a part of their work; the possible exception here is the medical profession, and doctorsâ involvement in health education is discussed at length in Chapter 7.
The maternity and child health services have a long tradition of educational work, based on the demands of their patientsâ condition. Midwives, for example, require co-operation from pregnant women for the success of antenatal care. An informed woman in labour is likely to be an easier patient to care for, since fear and tension may distort the course of labour.5 Physiotherapists, whether they are concerned with self-help techniques before the birth or with postnatal exercises afterwards, have no option but to teach, since clearly they cannot do exercises for patients. Similarly, midwives and health visitors cannot themselves look after babies for very long after birth, if at all, and therefore they teach mothers, and more recently fathers, to do so.
Teaching and Learning
The existence of well established health service teaching traditions justifies an examination of health service practice from an educational point of view. Education, however, involves activity on the part of the learner, as well as the teacher; indeed, the learnerâs activity is the more important, since it is possible for learning to take place without any direct teaching at all. Expectant and new parents, particularly women, are generally thought to be a particularly receptive group, willing or even eager to learn. The interest in teaching found among staff working with expectant or new parents in part reflects this willingness of their patients to learn. This very receptiveness may mislead health service teachers into concentrating on what they themselves wish to teach, rather than investigating what parents wish to learn, and what preconceptions, existing knowledge, or misinformation they bring with them to the encounter with professional staff. Good teaching is not achieved by treating learners as a passive audience; it does involve expecting and encouraging learners to take an active part in their own learning. Establishing links between old knowledge and new, or between established behaviour and possible new patterns, is part of the learning process. Teachers can make this easier for learners; but to do so they need to know something about individual learnersâ existing ideas and behaviour. This is easier in some situations than others, and with some patients than with others; the implications of encouraging active learning in practice is a recurrent theme of the following chapters.
Encouragement may be of particular importance to patients who are not very articulate, or lack self-confidence. Studies which document patient dissatisfaction with communication in the health service6 frequently include sketches of that apparently puzzling phenomenon, the patient who wants information but does not like to bother the staff by asking for it. One reason for this reluctance may be that in practice, in the health service, the initiative mostly rests with the professionals. They know the usual procedures. They can provide, or deny, the opportunity to ask questions without obviously disrupting the smooth flow of a clinic, or an antenatal class. They can assess more readily than inexperienced patients what is practical in a particular setting at a particular time, and because patients know this, they may well expect the opportunities for questions to be made by the professionals. Health service staff should be aware of the power they wield, so that they may use it in the interests of the individual patients they serve, and also so that where possible they can hand back responsibility for learning to the patients from whom it came. For learning is finally something which patients must do for themselves, and a passive trust in the benevolence and wisdom of professional staff, however justified this may be,7 will not foster active learning.
The Advantages of âAwkwardâ Patients
Passive patients encourage professionals to retain responsibility, and thus to discourage active learning. Since it may be easier to deal with patients who do not ask awkward questions, and who do as they are told, at least when the staff are present, professionals may not always find it convenient to encourage patient initiative. It is here that articulate, possibly âawkwardâ patients, pressure groups and voluntary organisations, have a value in encouraging good teaching practice within the health service. They may infuriate practitioners, but they do provide a continuous reminder that there are other things for a patient to resemble than a door mat. Staff who learn ways of meeting the needs of the articulate may also find that they can use what they have learned to encourage more passive patients, or to remove barriers to patient initiative of which they were not previously aware, because no one had challenged these barriers before. Professionals can do jnuch to improve patient education in the health service on their own. They can do more where patients help them to change their approach to learning and teaching. Learners have to make some effort to work with teachers, particularly where teachers have other things on their minds besides teaching, like the demands of clinical practice.
The Role of Patient Organisations
Voluntary groups can do more than act as hairshirts for professionals. In some instances they may provide an alternative education service, as does the National Childbirth Trust. Some health service staff who are critical of the NCT are inclined to see it as a threat to their own educational provision; they point out, with some justification, that it caters for the middle classes, and criticise its teaching on the basis of the, possibly âawkwardâ, patients they meet who have attended NCT classes. âAwkwardâ patients, as we have seen, have their uses, and material relevant to an assessment of NCT teaching is included in Chapters 2 and 3. Any voluntary organisation which provides classes for a clientele with special needs, whether it caters for intellectual career women in their thirties, unmarried mothers, or, in our multi-racial society, Mirpuri-speakers, may be a help to the health service staff by coping with the unusual type of patient who is difficult to deal with in the usual antenatal class. If the NCT provides well for one of these special groups, this justifies its existence. Voluntary organisations need not attempt to cater for all patients; that is the role of the health service.
Further, voluntary organisations catering for special groups may act as pioneers. They have great freedom to experiment; they have, almost by definition, enthusiastic staff, whether paid or unpaid, and a committed membership. They have an understanding of the patientsâ points of view which it may take considerable effort for a professional to acquire. They can therefore try new ways of meeting the needs of their own members which may later be of use to health service staff. Borrowing methods from enthusiastic self-help groups however, must involve some caution. They may suit the membership of that group, but they will not necessarily suit everyone. Local face-to-face groups may take on a particular social character which excludes others.8 This may or may not be because the members are âmiddle classâ, whatever that over-worked term means in a particular context. Professionals considering trying out new ideas used by voluntary groups will obviously bear in mind the context in which they are then being used, and that to which they are to be transferred.
Voluntary groups can help professionals to a better understanding of patientsâ needs, and can contribute some alternative methods of meeting them. Equally, voluntary organisations can learn from, and about, professionals. The more understanding they have of the nature of professional traditions, and the particular characteristics of professional working settings, the more capable they will be of helping their members to use the learning opportunities in the health service to the best advantage, without causing unnecessary friction. Professionals may be able to work with voluntary organisations towards improvements which both groups would wish to see. If this fruitful co-operation is to materialise, however, an understanding of one anotherâs strengths and limitations is highly desirable, if not essential.
The Uses of Local Studies
This book is based on a series of local studies, limited in both area and scale. The nature and uses of this type of evidence deserve some preliminary consideration, for local studies may contribute to two different types of examination of professional practice. In the locality where the work is undertaken, such studies may provide local health workers with material to assess their practice in terms of their own priorities, and, where necessary to act accordingly. The research on which this book is based has been discussed with managers and field staff and has contributed to that self-examination which is a part of truly professional work.9 In addition, the insights and experience of local professional staff have been of great value in the analysis of the material.
The alternative use of local studies is a more general one, and is the rationale for this book. There is no intention to imply that the results of these studies would be repeated in every ward, clinic or antenatal class up and down the country. Detailed, small scale studies instead enable the research worker to look for the dynamics of the situation, for the pressures operating on individual staff which lead them to behave in the way they do.10 Some of these pressures are undoubtedly local or individual: particular personalities, liaison problems, shortage of money, or design of buildings. But to try to explain good practice, or to explain away bad practice on these grounds does less than justice to other staff who manage well in difficult conditions. Explanations based on these individual or local characteristics are only partial. If, for example, staff are tired, or very rushed, they are obviously more likely to make mistakes. But the sort of mistakes they make will be determined not only by their individual personalities, but also by the ordering of professional priorities which they have learned and which may have become instinctive. The doctor who consults the midwife, but fails to speak to the woman in labour when he is called in at the end of a long period of duty, may behave like this because he is tired. But his bad manners also reflect a belief that talking to the patient is an optional extra. For him, the really important part of the job is to find out why the midwife thinks his presence is needed, and to do something about it. It is not enough to say that the man is tired, or to say that he is rude. Both may be true, in this situation. Neither is an adequate explanation of his behaviour. An understanding of his professional priorities is necessary for a more nearly complete picture.
Similarly, small scale studies make it possible to look closely at the problems of patients in particular settings, and in particular that of the patient who does not like to bother the staff. Staff who are only too willing to give information on request may find research which demonstrates patient dissatisfaction with this aspect of health service care both hard to accept and hard to act on if accepted. They are already willing to teach, and it is not easy to distinguish a patient who is too shy to ask questions from a patient who has no questions. Small scale studies may reveal barriers to patient initiative which could be dismantled, or circumvented, once staff are aware that they exist. For example, a patientâs belief that staff are too busy to teach may be true; it may also be based on a misunderstanding of how demanding the staffs activity is. Some jobs require concentration, but experienced staff can quite easily chat to patients as they put out or clear away equipment, or undertake routine examinations. The inexperienced patient may not realise this, and thus see no opening to ask a question, or raise a problem. Teaching in the health service, in a way that responds to individualsâ needs, has something to do with having a caring and responsive personality, but it may have a lot more to do with making apparent that willingness to care, to teach and to respond to individual need, to particular people, in particular settings, in particular ways. There are technical skills involved as well as personal characteristics; small scale studies can help to identify what those technical skills may be, so that they can be taught and practised more effectively in the future.
For teaching in health service settings has distinctive features, related to the blending of teaching with medical or nursing care. Staff have access to individual clinical information on patients, and can use this to relate each patientâs condition to that of the average patient. This information can be used in assessing the needs of each individual and attempting to meet them. For this reason no final substitute for teaching by health service staff is to be found in work by school teachers, by voluntary organisations, or through leaflets. Such work may be valuable, but it cannot take into account the circumstances of this patient at this time with this particular clinical condition. This information is only available when health service staff and patients meet; it is through the pooling of their joint store of information that the needs of an individual patient can be established, and the staff and patient together can make efforts to see that appropriate care and appropriate learning take place. This process is not simple, either to understand or to carry out, and it is in the belief that an improved understanding of the process can lead to improved practice that this book is written.
Notes
