Patient Lay Models Of Disease In Nursing Education

Nursing Education and Patient Lay Models Of Disease

What Patient Lay Models Of Disease In Nursing Education,Comparison to the Traditional Education Interventions In Nursing,View of Lay Models and Practices Discrepant with Modern Medicine,Outcomes of Lay Model Usefulness In Nursing Education.

What Patient Lay Models Of Disease In Nursing Education

   Patient “lay, or commonsense models, provide an example of both cognitive and constructivist learning approaches the models are cognitive but are constructed by the patient from his or her reality. Others have called these models schemata, explanatory, or implicit models. 

    Everyone forms them and they are recognized as fundamental to how people react to new information and how they cope with illnesses. They are frequently very resistant to change. Leventhal proposed that people have representations of illness that include ideas about the identity, cause, time line, consequences, and cure associated with an illness (Donovan & Ward, 2001).

Comparison to the Traditional Education Interventions In Nursing 

    Traditional educational interventions are designed to give the same information to everyone and to teach new coping skills without first addressing the well-established beliefs that drive the selection of coping strategies. A more effective approach starts with the patient describing his or her illness along the five dimensions of illness representation noted above including experiences that led to misconceptions. 

    Next, replacement beliefs and benefits to be expected from acting on the new information are introduced. Table 2.2 provides an example of this process with a program aimed at pain management of patients with cancer (Donovan & Ward, 2001).

    Significant amounts of research support the importance of perceived controllability of illness and its positive relationship to problem-based coping strategies, adaptive outcomes, psychological well being, social functioning, and negativity related to psychological distress and disease state. 

    Both the Illness Perception Questionnaire and the Implicit Models of Illness Questionnaire have been used in this research (Hagger & Orbell, 2003).

View of Lay Models and Practices Discrepant with Modern Medicine

    In some cases, lay models reflect cultural beliefs significantly discrepant with modern medicine. Kashmiri men in Leeds, with cultural norms that equate overweight with prosperity and well-being, are an example. Most of this population failed to control and manage their diabetic condition, with only 14% exercising and 84% continuing with their cultural foods, which were very rich in fats (Nacem, 2003).

    In other instances, differences in cultural beliefs between providers and patients are bound up in distrust of the medical system. 

    A study of beliefs of low income African Americans about hypertension showed interpretation of the frequent changes in medication required to achieve blood pressure control and minimize side effects as evidence of a conspiracy among hospitals, doctors, and pharmaceutical companies to exploit their group in testing medications, that is, to use them as guinea pigs in a covert experiment. 

    These patients expected medications to cure disease and so believed continuous, prolonged administration of them to be unnecessary. Because of these beliefs, many of these patients did not adhere to the regimen and put their trust in advice from family members and friends instead of health care professionals (Larkoschek, 2003),

    A final example shows how distress and dissatisfaction can result from differences between patients' and providers' models of illness and lack of attempts to understand and resolve them. Low-income Hispanic and African American women in primary care practice, who had abnormal findings on Pap smear, believed they had cancer and frequently believed it was caused by sex and sexual misbehavior. 

    The concept of pre cancer was difficult for them to understand, as was the inherent ambiguity of low-grade Pap smear findings. The women were informed of their results by letter and did not understand what it meant or what they were supposed to do. The women's explanations and concerns emerged only after systematic probing, which was not routinely being done in these practices (Karasz, Mckee, & Roybal, 2003). 

Outcomes of Lay Model Usefulness In Nursing Education

    Studies of lay models in cardiovascular illness are instructive. Older participants awaiting coronary artery bypass graft (CABG) surgery were significantly more likely to believe they had no control over the disease and that it would be gone after surgery and reported fewer health behavior changes than did younger participants (Grump, Matthews, Scheier, Schulz , Bridges, & Magovern, 2001). 

    Couples who had similar positive perceptions of the identity and consequences of myocardial infarction (MI) showed better physical, psychological, and sexual functioning with less impact of the MI on social and recreational activities (Figueiras & Weinman, 2003).

    Petrie, Cameron, Ellis, Buick, and Weinman (2002) note that despite the fact that fewer patients now die in the acute phase of MI, progress in improving functional recovery including return to work has been slower. Patient beliefs about their illness, assessed a few days after the MI, were key determinants of recovery (so these patients could be identified for an intervention). 

    Those who believed their MI would have serious long lasting consequences had higher levels of illness-related disability and were slower to return to work, and those with weaker beliefs in the control of their heart disease were less likely to attend cardiac rehabilitation. In this randomized controlled trial, an intervention conducted within the patient's normal hospital stay significantly altered incorrect beliefs. 

    The beliefs were maintained at 3-month follow-up and intervention patients were less likely than were control patients to report angina pain. The patient's model of his illness (as assessed by the Illness Perception Questionnaire) was the starting point. Frequently, patients' causal models had to be broadened to include lifestyle factors. 

    Building on causes as identified by the patient, a personalized written plan was developed to include exercise, dietary change, and return to work. Patients were also helped to distinguish symptoms that are a normal part of the health and recovery process from those that constitute warning of additional myocardial damage.

    In diabetes, personal models have been found to be stable over 3 months and predictive of outcomes in eating, glycolate hemoglobin, physical functioning, and mental health (Hampson, Glasgow, & Strycker, 2000). And a study of individuals with multiple sclerosis found illness representations to be the most significant predictors of social dysfunction, fatigue, anxiety, depression, and self esteem. 

    Lack of a coherent model of the illness predicted disability. As with the cardiac example given above, the suggested intervention is to explore patients' beliefs, assisting them to develop a more coherent understanding of their illness and identify symptoms that may be unrelated to multiple sclerosis. 

    Similar results have been found for heart disease, rheumatoid arthritis, cancer, chronic obstructive pulmonary disease, and others (Jopson & Moss-Morris, 2003). Yet another example is evidence that negative beliefs about the consequences of dizziness sustain long-term restriction of activity, which can be modified by therapy. Persons with dizziness frequently fear falling, fainting, or losing control. 

    Therapy consisted of explaining to the participant (with the aid of a booklet) how the balance system functions, the causes of dizziness and vertigo, why symptoms can be provoked by movement and how the process of compensation can be facilitated by exercises. 

    The nurse then guided participants through a set of eight standard head and body movements, instructing them to perform the exercises twice a day, gradually increasing the pace as the movement-provoked dizziness decreased. These exercises stimulate the vestibular organs and provoke dizziness, thus providing the balance system with the repeated exposure to movement necessary to achieve neurological adaptation. 

    Exercises were supplemented with walking and with training in relaxation, slow breathing, and graded resumption of activity. Significant reduction in negative beliefs was observed in the patients who received this treatment, whereas there was no such reduction in the untreated patients (randomly assigned). Beliefs were the primary longitudinal predictor of handicap (Yardley, Beech, & Weinman, 2001). 

    It is important to note what a profound conceptual and power shift is required to accommodate this more effective approach. The old “compliance to medical regimen approach” treated the provider's perspective as an uncontroversial point of departure with no questioning of the underlying socio-cultural assumptions on which the prescribed treatment regimen was based. 

    Patients were expected to accommodate this perspective. Compliance is built on providers' beliefs that technical control of the pathophysiology of the disease is the most important task, including control of the patient's behavior to that end. 

    In this approach, education is focused on correcting resistance to complying. Patients are more interested in how they are feeling and how much the illness and its treatment are disrupting their lives (Hunt & Arar, 2001).

    A meta synthesis of 292 qualitative studies on chronic physical illness shows the importance of patients being able to put wellness in the foreground with the self and not the disease or the body being the source of identity. 

    People are able to achieve this perspective by learning as much as they can about the disease, developing personal skills such as negotiating, creating supportive environments, and identifying the body's unique patterns of response. Self help groups can be counterproductive if they require the patient to focus on the disease instead of on a broader identity (Paterson, 2001).