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Chapter 8 Patient Education

Manual of Rheumatology and Outpatient Orthopedic Disorders

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Chapter 8 Patient Education

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John P. Allegrante

Definition
Goals of patient education
Diagnostic approach to patient education
Measurable impact and outcomes of patient education
Types of patient education
Educational and behavioral strategies for patient teaching
Selected sources of patient education materials and resources

Patient education is an integral part of the comprehensive clinical care of the patient with arthritis and musculoskeletal diseases. Most patients believe that education is very important to the management of their disease or condition. Planned educational interventions that specify measurable goals for knowledge, skills, and behavioral change, and that combine multiple educational and behavioral strategies, have been shown to have the greatest chance of producing potentially beneficial psychological, behavioral, and health outcomes in patients with arthritis and other chronic diseases. In addition to the impact on patient knowledge and attitude, there is substantial evidence demonstrating that patient education can enhance patient adherence to therapeutic regimens, produce physiologic and immunologic changes in response to behavioral change, and result in clinically significant improvements in health outcomes.

I. Definition. Patient education is defined as any combination of planned learning experiences designed to help people who are having or have had experience with illness or disease to make voluntary adaptations of behavior that will lead to better health. Education promotes understanding of the disease, a positive attitude toward recommended therapy , and the development of skills necessary to comply with therapy and cope with the illness experience. Patient education should be a process designed and tailored to help patients adopt, maintain, and prevent relapse of disease-relevant behavior.

II. Goals of patient education. The goals of patient education in the context of rheumatic and musculoskeletal diseases are to enable the patient to

1. Understand the disease and treatment(s).
2. Control or relieve pain and other symptoms.
3. Enhance psychosocial well-being by decreasing anxiety and depression and improving morale and motivation.
4. Control (if not alter) disease activity and its consequences.
5. Prevent or minimize disability.
6. Decrease inappropriate use of health services.
7. Increase the opportunities for independent living and enhanced functional health status, including employment and social functioning.
8. Improve skills to communicate with the clinician regarding symptom experience and treatment preferences.

III. Diagnostic approach to patient education. Several studies have shown that patients are often poorly informed about their disease and treatment and that large percentages of patients do not adhere to therapeutic regimens as prescribed. One approach to this problem is for the clinician to make an educational diagnosis and prescribe an educational plan. Educational diagnosis begins by assessing individual patient and family educational needs that are relevant to the disease and therapeutic goals.

1. Behavioral diagnosis. Determine what specific behaviors (e.g., keeping appointments, taking medications, exercising, changing diet, managing stress) are most likely to contribute to achieving the desired clinical outcome.

   Prioritize these behaviors in terms of importance and potential for change, and focus on one or two behaviors that the patient is likely to adopt early and successfully.

2. Educational diagnosis. Once target behaviors have been specified, identify those predisposing, enabling, and reinforcing factors that are most likely to contribute to the performance of the behavior(s) of interest.
   1. Predisposing factors. Patient beliefs about the disease and efficacy of treatment play an important role in determining patient compliance with medical regimens. Patients' beliefs about their ability to cope with and control the effects of their disease appear to be especially important in managing the symptomatic experience of chronic illness. The first step in an educational diagnosis is to assess the patient's knowledge and beliefs about the disease and disease process, including perceived susceptibility, severity, and seriousness of the disease or condition and perceived costs and benefits of treatment. Assessment of psychological factors such as patient motivation, self-esteem, perceived self-efficacy, and locus of control is also important. Several standardized measures are available to assess these and other patient beliefs.
   2. Enabling factors. Research in health education has shown that although knowledge is necessary before behavioral change can occur, knowledge is not sufficient. Patients need to possess the skills and resources necessary to make behavioral changes. Communication skills and the skills to perform specific disease- related management tasks , such as exercising, taking medications, and monitoring and documenting progress accurately, permit patients to put into action what they know.
   3. Reinforcing factors. Family members, members of the health care team ( physician , nurse, physical therapist, occupational therapist, social worker), and even other patients can play an important role in reinforcing patient behavior through their attitudes, values, and behavior. When possible, assess the impact of these reinforcing factors and coordinate patient teaching and reinforcement of instructions to patients with other professionals, family members , and significant others.

IV. Measurable impact and outcomes of patient education

1. Patient knowledge, attitudes, and disease-management skills.
2. Informed consent .
3. Decision-making skills and coping behavior.
4. Communication skills.
5. Frequency, duration, and quality of behavior (e.g., complying with therapeutic regimens, keeping appointments, and other coping or disease-management behavior).
6. Health outcomes (e.g., measures of functional status).
7. Use of health services (e.g., reducing cost of episodic hospital care, rate of rehospitalization).

V. Types of patient education

1. Preoperative education prepares the patient for the experience of surgery and what can be expected, by teaching relaxation and other coping skills that can reduce patient anxiety, length of hospital stay, postsurgical complications, use of pain medications, and overall hospital costs.
2. Medication self-administration education programs educate patients and family members to take responsibility for administering medications in the context of home health care, often with medication error rates that are comparable with or below those of nurses and other health professionals.
3. Outpatient education programs include pre-admission education designed to orient the patient to diagnostic and therapeutic procedures in the hospital, community education designed to focus interest on population-wide disease risk factors and screening, and post- discharge education designed to foster social support for groups of patients.
4. Discharge planning education facilitates the transition from hospital care to home health care or nursing home care by educating the patient and family about the patient's post-hospital needs and how to access community resources to meet those needs.
5. Family education is typically incorporated into most types of patient education, but it is especially important in the treatment of patients with severely disabling diseases and conditions, elderly patients, and patients who experience complications during their hospital stay.
6. Peer education and social support programs enlist the cooperation of lay volunteers who have experienced an illness or condition in teaching patients and providing social support; these have been shown to be especially valuable in cases of chronic diseases and illnesses that stigmatize, limit social interaction, or result in severe functional impairments.
7. Cooperative care is inpatient hospital care that encourages the participation of a family member in providing patient care and uses education to improve family knowledge and satisfaction with care, adherence to treatment, and self-management .
8. Early discharge education has been developed in response to the cost-containment tool of diagnosis-related groups. It is used with patients who meet strict eligibility criteria for early discharge from the hospital and is designed to facilitate the development of appropriate patient self-care skills before the patient leaves the hospital.
9. Home health education programs educate patients and family members to perform clinical procedures and use technologies that are typically confined to hospitals and require professional supervision.
10. Mutual aid and self-help groups can be hospital- or community-based and led by lay or professional people. They provide patients who have chronic illnesses and their families with an important source of education about the disease, emotional and instrumental social support, and advocacy .

VI. Educational and behavioral strategies for patient teaching

1. Use direct instruction during the clinical visit, and repeat and reinforce instructions to patients during subsequent visits .
2. Encourage patients to take notes during the clinical visit and to write down or record instructions.
3. Have patients clarify instructions by repeating them back to the instructor, and encourage questions during the clinical visit.
4. Have patients set short- term goals for behavior change that are challenging yet manageable and that are reinforced with predetermined rewards.
5. Encourage patients to use self-monitoring strategies, such as checklists, diaries , and other devices, that help them to measure progress and document achievement of goals.
6. Have patients sign a written contract that specifies the frequency, duration, and quality of behaviors that are expected to be performed; have a family member witness and co-sign the behavioral contract.
7. Prepare written instructions and tip sheets for patients about medication and other complex aspects of a therapeutic regimen in advance of the clinical visit; distribute these in clinic or office waiting areas.
8. Telephone patients a day or two following an office visit to follow up, clarify, and reinforce instructions.
9. Include a family member or significant other when presenting instructions to patients; have the family member take notes.
10. Utilize a variety of audiovisual aids when teaching patients, including printed materials such as diagrams, tip sheets, pamphlets, newsletters, and videotape cassette presentations.
11. Provide language translations and large-type versions of instructions to patients as appropriate.

VII. Selected sources of patient education materials and resources

1. American Hospital Association, Chicago, IL, promulgates guidelines and policy statements and sets standards for patient education as part of the hospital accreditation process.
2. Arthritis Foundation, Atlanta, GA (telephone: [phone]) and local chapters produce a range of printed information pamphlets and educational audiovisual programs for patients, publish a patient newsletter, and will provide information about mutual aid and self-help groups for people with arthritis. These include the SLESH (systemic lupus erythematosus self-help) course, PACE (people with arthritis can exercise) course, and ASH (arthritis self-help) course.
3. Arthritis Health Professions Association, Atlanta, GA, publishes Arthritis Care and Research, which contains articles about research and evaluation studies of arthritis patient education.
4. International Patient Education Council, Rockville, MD, publishes Patient Education and Counseling, a leading journal devoted exclusively to issues, reports of research, and case studies of patient education.
5. National Institute for Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, provides information about patient education research in arthritis and musculoskeletal diseases being conducted at multipurpose arthritis centers, through which technical assistance in developing patient education programs is usually available.
6. National Project for Self-Help Groups, Fairfax, VA, serves as a clearinghouse and provides access to hundreds of mutual aid and self-help groups for patients with chronic diseases throughout the nation.
7. Society for Public Health Education, Washington, DC, publishes Health Education and Behavior, a leading journal devoted to health education research and practice, including patient education.
8. Ankylosing Spondylitis Association. 14827 Ventura Blvd., Suite 119, Box 5872, Sherman Oaks, CA 91403.
9. SLE Foundation. 149 Madison Avenue, Suite 205, New York, NY 10016.
10. Scleroderma Foundation. 2320 Bath Street, Suite 315, Santa Barbara, CA 93105.
11. Sj gren's Syndrome Foundation. 333 North Broadway, Suite 2000, Jericho, NY 11753.
12. Wegener's Granulomatosis Foundation. 9000 Rockville Pike, Bldg. 31, Rm. 1B 30 W, Bethesda, MD 20892.
13. Osteoporosis Foundation. 1232 22nd Street NW, Washington, DC 20037-1292.

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Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

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