Introduction:
There have always been many difficulties in catering to the needs of Patients with Chronic Complex Health Care Needs. The rising prevalence and morbidity associated with chronic medical conditions across the world has prompted a re-evaluation of the procedures employed to manage the condition as well as exploring new training methods for educating patients to take care of themselves. This report looks at one particular disorder – asthma – and tries to evaluate a new plan of education, devised to educate patients to scientifically and effectively use the inhaler. The patient participating in this study will be referred to as Lisa in order to maintain confidentiality. But first, a glimpse into what is the state of existing patient education systems is warranted.
Healthcare institutions concerned with respiratory disorders have been in existence for many decades now. In the case of the United Kingdom, the Asthma Training Centre (ATC) was established in 1986 and has done commendable work in alleviating the suffering associated with this illness. This charitable foundation was set up with a grant from the Asthma Society (now the National Asthma Campaign), and contributions from the pharmaceutical industry. Although its initial days were a little shaky, the continued pursuit of their long-term objectives has paid off for the ATC, which now owns two large medical facilities. While most training programs implemented by organizations like ATC are of high merit, the changing nature of chronic health-care and changing medical interventions require a modified education program. This applies to the effective use of symptom control devices like a salbutamol inhaler as in the case of chronic asthma.
Before charting out the plan for patient education, a look into some key considerations is called for. A comprehensive education program directed at practice-nurses is of high significance. These practice-nurses are not only directly involved in handling asthma patients during the course of their practice, but will also serve as suitable trainers for patient education programs. The training program that will be designed and implemented as part of this exercise will try to follow the ATC model, which has a qualified team of nearly fifty regional trainers “who are lecturers recruited from the ranks of the original practice-nurses”. Other pre-requisites for choosing practice-nurses include their previous experiences in “maximal nurse involvement” cases, so that they are thoroughly knowledgeable and equipped to deal with all sorts of questions during the patient-training programs (Buckner, 2005). While the program pertaining to the use of inhaler is a relatively simple one, the systematic approach with which it is carried out can be adapted to any other chronic medical conditions as well.
The training program that is to be designed will also have to include research design and statistics components that are developed in association with the Applied Psychology Research Group. The research projects that result from these training programs will later be integrated with special research groups dedicated for the implementation of further programs in asthma patient education. Moreover,
“Specialized courses will be developed for nurses working in specialized settings, such as in school and paediatric nursing, as well as those working in respiratory medicine. Programs in allergy management are also highly relevant and this program will have to be developed in collaboration with the British Society of Allergy and Clinical Immunology”. (Barnes, 1994)
An important challenge for patient-trainers is making sure that the patients are using their inhalers “appropriately and correctly” (Barnes, 1994). It has to be kept in mind that a written instruction is always preferable to orally passed on instructions. These written instructions also called action plans. The trainers must also check with the patient if they are employing the right technique in using the inhaler. A newly-diagnosed patient needs to be taught how to use the inhaler in order for it to be effective in alleviating the symptom temporarily. The significance of an audio/visual approach to training cannot be overstated. Hence, the leaflet handed to the patient must have illustrations and suitable use of colour. The psychological and cognitive factors in transmission and assimilation of information need be factored into the assessment. The following four steps are a handy reference for patient-educators to check for the above key indicators of the effective employment of the inhaler.
(a) Adequate preparation of the inhaler by shaking the canister and removing the mouthpiece cap;
(b) Adequate expiration accomplished with the head in the correct position;
(c) Adequate slow inspiration to total lung capacity; and
(d) Breath held subsequent to inspiration. Implicit in this audit is coordination of canister actuation with the beginning of inspiration. (Buckner, 2005)
Planning:
What follows is a brief overview of the planned education program:
Accurate diagnosis of the patient’s asthmatic condition and initial treatment plans with a short explanation of prescribed medicines as well a demonstration of the correct inhaler technique is scheduled for the very first visit. A more detailed diagnosis as well as a more comprehensive education session can be slated for later visits.
One of the basic objectives for the education program includes facilitating asthma patients to keep their condition under control under any circumstance. Also, the program will aim to use the available resources efficiently, to help patients regain and maintain their independence, and to keep them motivated for further learning. The program tries to achieve these essentials by adhering to sound educational principles. These education principles include “providing information in small bites, using simple terms, encouraging the use of resources, being flexible, relevant, optimistic, and sensitive”. The instructor makes sure that the information given is comprehended, and also encourages queries from participating patients (Hume, 2002).
The management and training of Asthma will be made compatible with the existing primary care pattern of small but frequent sessions. For example, the sessions might last approximately ten minutes. Since most patients do not retain most of what they learnt in the therapist’s office, their methods and techniques of using the inhaler might be incorrect. This is where the ten minute sessions come very handy, as the amount of information passed on to the patient is quite small and easy to assimilate and remember. To back this up a written version of the instructions are also handed to the patients. The following is an overview of what’s been planned for their subsequent visits:
“Subsequent visits are used to check what has or should have been learned, to correct misunderstandings, and to impart new knowledge. New patients, if stable, need to be seen at least every 2 weeks. Patients who are unstable or who present in a more acute stage must be followed up more frequently, as their condition dictates. As patient knowledge and asthma control improves, the frequency of visits may be decreased. At the stage of apparent stability, it is important to review, at each visit, some aspect of the patient’s asthma education, including the action plan and inhaler technique” (Hume, 2002).
The importance of follow-up visits is not lost while drawing up the plan of action. These subsequent visits are great opportunities for identifying patient misunderstandings with respect to asthma control practices. In addition to serving as opportunities for patient education, these sessions help make an assessment whether to increase or taper off the maintenance therapy. This is a crucial decision, as the lowering of treatment to minimum effective drug treatment at the correct time is equally important as increasing the intensity of treatment (Slutsky, 2001).
Among asthma sufferers, children form a separate category. Education methods suitable for adults will not be appropriate for children. Also, education directed at children will be something that they will carry for the rest of their lives. In this sense, the resources and effort spent on education young asthma patients is a good investment. Accordingly, the education program designed as part of this essay includes “community asthma classes in schools, day-care centres, churches, and community centres”, which are convenient places for children to attend (Slutsky, 2001).
Hence, the program adopts a family-centric approach in all its modules. The education sessions are so scheduled that both parents and children are trained simultaneously in separate enclosures. Further, regular revisions are undertaken for the aid of “parent facilitators, peer educators, school nurses, childcare providers, and child welfare agencies in the targeted community”. The program is also slated to adhere to time-tested methods of delivering inhaler usage modules that covers the basic requirements.
The following is the planned outline of different parent sessions:
Session 1 Introduction to asthma in general
What is asthma and why does my child have it? In this session parents will explained how asthma affects their child's body.
Session 2 Triggers of Asthma and Prevention Techniques
In this session different things in the environment that trigger asthma are talked about. Parents are taught how to avoid these triggers and to prevent an asthma attack from starting.
Session 3 Medicines and Asthma Devices (focusing on the use of inhaler)
In this session various differences in the medicines, how they work to keep asthma symptoms from starting, etc are discussed. Th e purpose of the asthma devices (inhaler, spacer, and peak flow meter), the proper way to use them, and how to take care of them are also discussed.
Session 4 Asthma Action Plan
This session will deal with the usage of peak flow meter and the inhaler to help parents make a medicine plan for their child. This will give parents the information that they will need to treat asthma early when they occur.
Session 5 School and Family Issues and Questions and Answers
Ways to help teachers and school nurses to deal with the child's asthma are explored. A look at how asthma affects the family as a whole and what the family can do to relieve stress, yet at the same time be supportive to their asthmatic child is analyzed.
While the above education plan is specifically designed for parents of asthmatic children, they are equally applicable to adult asthma patients also. In this case, the adult patients will assume the role of their own parents. The above plan of training was put through a test run, in order to check its efficacy. The following table was employed to gauge the effectiveness of the program. Again, this evaluation tool is the one used for adult patients. The table for asthmatic children is very similar to this (Boychuk, 2006).
Implementation:
The above set-out plans were implemented by paying attention to the smallest of details in the plan. The following were the various components in the implementation of the action plans:
1. Demonstrating the inhalation technique using a placebo inhaler, followed by patient rehearsal of the technique, till she reached a satisfactory level of applying the inhaler.
2. Care is taken to make Lisa feel comfortable in during the session. This is done by using words of encouragement and by adopting an unconditional positive regard to teaching (in other words, a humanistic approach).
3. A friendly rapport was developed with the patient by being approachable and by making the education session an interactive one. It is intended that the confidence levels of the patient will be increased due to such an approach.
4. Concepts from Adult Learning theory was applied during the session, in order for it to be a scientific one.
5. Also, Lisa was given an overview of what she can expect during and after the session. She is also make aware of the objectives of the session and made to see the benefits in learning the correct procedure of inhaler usage (Ebbinghaus, 2003).
Evaluation:
The following check-list comes in handy while evaluating how effective the asthma education program has been and how successful it has been in meeting objectives:
* What are the changes in measured peak expiratory flow (PEF) rates during the training period?
* What is the change from before to after the program regarding knowledge about asthma in general, inhaler application in particular and self-care management?
* What is the change from before to after leaning the usage of inhaler, regarding general resilience to an asthma attack?
* What are the changes in the patient attitudes and feelings about the usage of inhaler during the course of the training?
* What are the general perspectives from patients and their care-takers concerning the outcomes of the education program? (Owen, 1994)
Conclusion:
This report had achieved what it set out to do in the beginning. By presenting inhaler education over a longitudinal time period each topic was comprehensively covered. Group interactions, which allow caretakers (in case of child asthmatics) to share information and experiences, have also been incorporated into the program. It is hoped that this interactive education program provides motivation towards asthma self-management for participants like Lisa. Several scientific techniques were incorporated into during various states of its execution in order for the presentation of content to be more effective. These include positive inducement of group dynamics and support that allow more experienced and knowledgeable users of inhalers in the group to help those who are less knowledgeable and motivated, which further enhances learning. Presenting an educational material that is embedded with illustrations and other visual aids had helped transmit the information successfully.
At the end of the class series, participants complete evaluations that measure knowledge, quality of life, and self-management behaviour outcomes of the program. It is scheduled to call all participants (including Lisa) at 3, 6, and 12 months after completing the classes to confirm retention of the material learned in class. By making the patients take control of their asthma management in general and inhaler application in particular they are able to take their medicines properly, recognizing, reporting, and treating asthma symptoms promptly. Further, since all of the sessions were held at community-based settings, a high rate of enrolment and retention is evidenced (Boulet, 1994).
In the process of carrying out this exercise, the following area of deficiency with the present execution was identified:
“Barriers to participation, such as inaccessible locations and times when classes are offered, need to be eliminated in order for patients and their families to attend and fully participate in the inhaler educational program. Programs that are community-based have been shown to be most effective. Such programs also need to be highly accessible to patients and their families who live in urban inner-city communities to insure recruitment and retention of participants” (Owen, 1994).
The report also identifies the importance of follow-up sessions to ensure that the patient is able to retain the learned skills in using the inhaler. This way, the patient can continue to manage his/her asthma with the least amount of medication. The follow-up plan is also so scheduled keeping in mind the patients’ level of understanding and the nature of their asthma.
References:
Barnes, Greta R., and Kenneth R. Chapman. “Asthma education: the United Kingdom experience. ” Chest. 106.n4 (Oct 1994): 216S(3).
Owen, Grahame. “Consideration of program and techniques for general practice. ” Chest. 106.n4 (Oct 1994): 235S(2).
Buckner, Ellen B., Ashley M. Hawkins, Lynn Stover, Jennifer Brakefield, Sharon Simmons, Cynthia Foster, Sheree L. Payne, Jean Newsome, and Gustavo Dubois. “Knowledge, resilience, and effectiveness of education in a young teen asthma camp. ” Pediatric Nursing. 31.3 (May-June 2005): 201(8).
Hume, Leigh. “A wheeze by any other name? (Critical Thinking in Critical Care). ” Pediatric Nursing. 28.4 (July-August 2002): 390(2).
Slutsky, Phyllis, and Tyra Bryant-Stephens. “Developing a Comprehensive, Community-Based Asthma Education and Training Program. ” Pediatric Nursing. 27.5 (Sept-Oct 2001): 449.
Boychuk, Rodney B., Charles J. DeMesa, Kristi M. Kiyabu, Franklin Yamamoto, Loren G. Yamamoto, Ron Sanderson, Brenda Gartner, Rebecca Donovan, Sheila Beckham, Corilyn Pang, Rebecca Fanucchi, and Valerie Chong. “Change in approach and delivery of medical care in children with asthma: results from a multicenter emergency department educational asthma management program. ” Pediatrics. 117.4 (April 2006): S145(7).
Ebbinghaus, Simone, and Abdul H. Bahrainwala. “Asthma management by an inpatient asthma care team. (Continuing Education Series). ” Pediatric Nursing. 29.3 (May-June 2003): 177(7).
Boulet, Louis-Philippe, Kenneth R. Chapman, Lawrence W. Green, and J. Mark FitzGerald. “Asthma education. ” Chest. 106.n4 (Oct 1994): 184S(13).