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.