Who is Teaching the Teachers?

Recently, I got into a discussion with some friends about Adult Learning Principles, and how some providers do a fantastic job teaching patients, while others really struggle, which greatly affects care. The overall topic was how profoundly our approach matters in basic communication, and how instant negative associations are made from misunderstandings on a constant basis—especially in the clinical setting.

As a nurse, I have found that quite often at the end of our education, we are directed to apply the medical concepts we know, and “instruct the patient,” but seldom with guidance on how that is supposed to be accomplished. On one side of the stethoscope you have a rushed, overworked, provider trying very hard to get through to the next appointment, and on the other, a human being quite possibly having one of the worst days of their lives. There is an instant disconnect.

The Amygdala Processes Fear

Patients often say their providers are out-of-touch and cold. What if they are right about that? I certainly believe them! We should ask ourselves if we are recognizing our patient’s emotional state, responding to it empathetically, and keeping a safe space open for discussion, especially when the patients are acting like they can’t hear us. Do we even remember why this is important? When was the last time you really thought about how a triggered amygdala makes complex thought formation impossible?

Learning anything in a crisis is like trying to pay attention to an e-book about ornithology while standing in the middle of fast-moving, oncoming traffic. You can’t think about anything when your physiology is forcing you into survival mode. You certainly can’t listen to the birds. This is the emotional state of most of the patients we see in our space. We would be doing better if we kept that in mind.

To a provider, a miscommunication in the clinic may sound like, “the patient is non-compliant” or, “the patient doesn’t care.” To a patient, it may sound like, “that nurse thinks I’m stupid” or, “the doctor is really full of herself,” but if neither party is understanding the other’s needs, abilities, or expectations, how is anything at all ever going to be accomplished?

Adult Education in Nursing

I am going to disclose something I have often found puzzling in my career…I have never had to take an actual course in adult learning. I did take one—for fun—as an undergrad because my roommate was an education major and I was learning by osmosis a bit. After that, I received little, if any, formal training in how to connect with patients, or educate them, let alone how to deal with complex educational issues such as systemic inequality, abject illiteracy, and overcoming learning disabilities. I learned to teach intuitively, and only much later realized that there are entire academic fields dedicated specifically to how adults need to be taught!

Recently, I did a quick survey of my co-workers and friends, many of whom hold master’s level (or higher) degrees and was even more surprised to find out that while most of us had surveyed adult education within other courses, basically no one had it formally enshrined into their educations. This makes no sense! Education is so integral to what we need to be doing more of within this industry! Students: take adult education as an elective; it is truly at the heart of everything!

One of the most challenging tasks we face in medicine is having to effectively teach people from all walks of life while they are in various states of being physiologically unable to learn. It is in our job descriptions and well within our scopes of practice to this. Why have we never been shown exactly how, then? Why are we forgetting the nervous system and stress hormones? Why are we not addressing those feelings first and calming down the amygdala? This is where science and common sense intersect.

Furthermore, why are we expecting adults who are sick to both behave like adults and learn like children? Are we missing andragogy—adult learning—completely? I believe we may be!

Adults Learn Differently Than Children

You see, unlike children, adults have a concept of self already established. They understand right from wrong very clearly and are capable of having complex ethical debates in their own minds. An adult does not need to be told “this is good” or “this is bad,” because they usually are already aware, and no one enjoys being patronized. That does not tame an amygdala; it frustrates it with distraction. Scolding a grown-up does not make them feel like learning anything. If you are doing this, you are not educating.

They can’t hear you.

An adult who is engaging in a harmful behavior is often doing so with some level of understanding about the choice. A child’s learning can be influenced by peer pressure, but an adult usually isn’t. An adult truly needs to be self-motivated to learn and do the things they want to do. This includes changing their health and lifestyle behaviors. An adult needs to feel like they’re doing something well, so they can do it better. A child may learn because a teacher tells them to learn, or may change behavior when an elder directs them to. Adults are not the same.

Our adult patients have memories, circumstances, experiences, traumas, feelings, obligations, thoughts, fears, hopes, aspirations, and a deep emotional universe of their very own: just like we do. How we approach education, with recognition of humanity (this includes brain chemistry!) and knowledge of how to approach an adult learner in the first place can make the seemingly impossible task of connection much more possible. An adult cannot be made to learn sequentially, as a child does. An adult must make an active choice to learn, and has to see a benefit to the education to be motivated enough to bother with it.

Why are clinicians not being given this information in heavier doses? Why is something so basic so tragically overlooked? Readers—what is your level of education, field of expertise? Have you ever taken a whole course on adult education fundamentals? How did you learn to speak to people in crisis? How did you learn how to teach? I really am curious!