Patient Education In Chronic Diseases In Nursing and Advances in Learning Theory
Advances in Learning Theory for Patient Education
Advances in learning theory important to patient education have evolved slowly over time. General learning theories of constructivism and cognitive load provide new insights. More specific to patient education are learning more accurate symptom perception, the importance of assessing and incorporating lay models into teaching, and enlarging concerns about health literacy.
Specificity of Learning Theory for Patient Education In Health Care and Education
There is no unified theory of learning, but rather theories that cluster into perspectives. The objectivist perspective with an aim in making learning more scientific and measurable was dominant throughout most of the 20th century.
It has included work on learning as a biochemical activity in the brain, the behaviorist approach, which aims for a relatively permanent change in behavior and notes that people respond in predictable ways if they are reinforced for their performance; and the cognitive approach, which holds that learning involves more sophisticated methods for processing, storage, and retrieval of information.
The cognitive perspective incorporates a focus on
critical thinking and on development of schemas, which will be further
described in a following section on lay models (Jonassen, 2003).
The constructivist perspective defines learning as knowledge construction, in which individuals make sense of their world by constructing their own representations or models of their experiences. On this view, learning involves social negotiation of beliefs, out of which comes conceptual change.
Individuals make sense out of domain concepts in such a way that they develop coherent conceptual structures they organize and reorganize their naive models of the world in light of new experiences.
The more coherent these theories are, the more meaningful and useful they are. Constructivists believe that learning requires activity with authentic materials and situations, with the goal of developing skills and abilities to be used in real life. We understand our reality only in the form in which it has been constructed by us, not that imposed on us.
Under constructivism, teaching by transmitting prepared
packages of knowledge separated from concrete situations can- not be justified.
Rather, the task of the teacher is to create stage environments where learning
can be constructed (Jonassen, 2003; Terhart, 2003).
Part of a cognitive perspective, recent work on cognitive load theory focuses on what makes things complex and difficult to learn. It holds that instruction should be structured to reduce unnecessary extraneous working memory load.
Some of this load is intrinsic to the intellectual complexity of
information, making it difficult to break into individual chunks and learn
separately until learners develop sufficiently complex schemata (Pollack,
Chandler, & Sweller, 2002).
Much patient and health education practice were developed during a time when cognitive theory was dominant and has also integrated a structured, scientific approach to learning with measurable objectives to be met through changes in knowledge and behavior. This still dominant approach has not yet accommodated constructivist philosophy or approaches to learning (Soto Mas, Plass, Kane, & Papenfuss, 2003).
It is easy to see that a constructivist approach would require a much different learning environment with realistic laboratories or instructor immersion in the patient's daily life. More important, patients would define the questions they need answered and the skills they are lacking. Instruction under this philosophy has the potential to be much more effective and useful than are current methods.
Patient Perception In Response to Chronic Diseases an Education
Particularly in chronic disease, the patient's ability to accurately perceive symptoms is essential for triggering decision processes to initiate treatment. This ability is not necessarily closely related to intellectual knowledge of disease processes or treatment measures, which is the traditional content of patient education.
Perceptual accuracy is the degree to
which subject. assessments of symptoms correlate with objective measures of
severity (Yoos, Kitzman, McMullen, & Sidora, 2003). The most work has been
done in diabetes with blood glucose discrimination training and to a lesser
extent in asthma.
A highly disruptive example can be found in perception of heart palpitation. Benign palpitations with no comorbid cardiovascular disease are common, reported by as many as 16% of patients in general medical settings, the second most common reason for referral to cardiologists. Palpitations are experienced as an uncomfortable awareness of a beating heart, pounding or racing of the heart, missing a beat, or flip flopping in the chest.
More than half of patients reporting palpitations do not have clinically significant arrhythmias. These patients often undergo a variety of diagnostic procedures, frequently repeated because knowledge of negative test results doesn't seem to change patients' perceptions that their heart function is abnormal. They are difficult to reassure.
A short term intervention consisting of information about causes of
palpitations, discussion about the patient's beliefs about the symptoms, and
advice on coping with them have been shown effective in decreasing symptoms and
improving mood (Ehlers, Mayou, Sprigings, & Birkhead, 2000) . This
intervention aims to change the meaning of the symptoms, not necessarily the
accuracy of their perception.
Blood glucose awareness training (BGAT), also called blood glucose discrimination training, teaches more reliable perception of physical symptoms such as mood changes or deterioration in mental function and external cues like food intake and physical activity. The training lasts 8 weeks with weekly sessions of 1-2 hours and aims to improve patients' ability to detect and predict extreme fluctuations in blood glucose accurately (Gonder-Frederick, Cox, Clarke, & Julian, 2000).
Blood Glucose in Diabetes and Patient Education
Because extremes in blood glucose (BG) levels can have an impact on nearly every organ system, including a dramatic impact on the central nervous system, the list of symptoms that can be caused by hypo- and hyperglycemia is long and not specific (can be caused by other physiological states). In addition, BG symptomatology is highly idiosyncratic with no one symptom associated with hypo or hyperglycemia for all patients.
Some, such as fatigue,
may signal low BG in one patient and high BG in another. Idiosyncratic symptom
clusters are stable over relatively short periods such as 3-6 months but may
change dramatically over time. In fact, symptoms may vary across different
episodes of hypo and hyper glycemia for an individual patient (Gonder-Frederick
et al., 2000).
There are individual differences in the number and intensity of symptoms and the glycemic threshold at which physiological responses and subsequent symptoms occur. Thus, some patients become quite symptomatic with relatively mild hypo- or hyperglycemia, some notice nothing until their BG is extremely low or high and they are severely impaired, and some never recognize them.
In general, hypoglycemia is more symptomatic than hyperglycemia, which tends to be associated with symptoms that are less intense perceptually and slower in onset. In contrast, hypoglycemic symptoms often onset suddenly and can be quite aversive. Patients need to be taught about the idiosyncrasy of BG symptoms and helped to identify those that are personally most reliable.
There
are large individual differences in accuracy, significantly poorer in younger
age groups such as adolescents, with patients' confidence in their ability not
related to objective measurements. Few patients demonstrate acceptable accuracy
at every BG range. Self measurement of blood glucose (SMBG) feedback is not
obtained frequently enough to guide all self treatment decisions
(Gonder Frederick et al., 2000).
The 8-week BGAT training requires patients to make diary entries at least four times a day before their routine SMBG and whenever they believe, because of internal and external cues, their BG may be too high; they then measure and plot actual BG and learn their most reliable symptoms.
Weck 3 is devoted to neuroglycopenic symptoms to increase patient sensitivity to the often-ignored, subtle, and early signs of deterioration in mental and motor function due to mild hypoglycemia. Patients learn to use self-tests, such as how long it takes and how much effort to do mental arithmetic, compared with their usual speed and difficulty, to assess their own ability to function.
Patients learn to monitor the fat content of their food since high fat can cause a significant increase in digestion time, which can dampen and/or delay BG increase (Gonder Frederick et al., 2000).Only 15% of BGAT patients reported auto accidents while 42% of control patients reported one or more, there were also significant decreases in severe hypoglycemia and nocturnal hypoglycemia.
Strong intrinsic motivation and willingness to do SMBG several times are important because a large investment of time and effort is required. Good fundamental knowledge about diabetes and its treatment is also required. As yet, this education has not been modified for children who frequently make a high rate of errors (Gonder Frederick et al., 2000).
In an attempt to reduce driving mishaps in patients with type 1 diabetes (who report twice as many driving accidents as do their spouses), Cox, Clarke, Gonder Frederick, and Kovatchev (2001) have developed hypoglycemia anticipation awareness training (HAATT).
It is designed specifically for patients who have problems with recurrent severe hypoglycemia. In driving simulation tests patients frequently did not recognize and failed to treat hypoglycemia before their driving performance began to deteriorate. Learning to test before their drive and to detect low BG levels before they become impaired are important outcomes of HAATT.
Asthma and Patient Education
A similar large variation in ability to accurately perceive the severity of broncho constriction occurs in asthma. Adequate asthma self-management rests on the ability to detect changes in peak expiratory flow (PEF) of about 15% and then taking action to abort an impending attack. Smaller changes may not be detected by adults. Blunted perception of symptoms is associated with fatal asthma.
A life threatening attack of airway obstruction can develop within 1 hour. Asthmatics may consider themselves symptom-free in the midst of an asthma attack or suffer from severe breathlessness during mild airway obstruction. Other asthmatics may not feel well during airway obstruction but do not know what is wrong.
In fact, they may attribute their
condition to having the flu or needing rest. Rapid awareness of symptoms and
taking the required medications can be decisive. Likewise, over perception
problems lead to excessive use of medications and unwarranted illness behavior
(Rietveld & Everaerd, 2002).
As with diabetes, symptom perception accuracy in children and their parents was inaccurate about one third of the time and at sick times when the child's peak flow reading is at less than 80% of personal best, accuracy decreased markedly to one third of episodes being correctly evaluated.
Yoos et al. (2003) note that peak flow meters are more sensitive to large airway than to small airway resistance, in addition, patient adherence to them is low (about 28%).Unlike with diabetes, there have been only modest attempts to improve symptom perception in asthma.
Measurement of perception of dyspnea should be performed at least once in all asthma patients, to identify those at risk for fatal attack (Magadle, Berar Yanay, & Weiner, 2002), and especially in those who have frequent emergency room visits. Keeping a diary of perceived breathlessness and corresponding PEF and looking for the largest PEF change and its related perceived level of breathlessness is recommended.
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