Are theoretical concepts necessary
At this point we would like to introduce you to some basic theoretical concepts of patient education. A list of literature with a selection on the subject of “theoretical foundations” can also be found here.
Model of salutogenesis
The model of salutogenesis according to Aaron Antonovsky has proven to be particularly viable for our work. This model is based on the assumption that all human beings are on a health-disease continuum; it removes the dichotomy of health and disease. People are healthy and sick at the same time, this also corresponds to the perceptions in everyday care. Salutogenesis also describes the sense of coherence (SOC), which expresses the individual's inner confidence that requirements can be explained and that supporting resources are available and that commitment is worthwhile. Antonovsky uses the terms understandability, manageability and meaningfulness to describe this.
In our opinion, patient and family education should "promote coherence". Antonovsky's views are compatible with other models and theories, which also postulate knowledge, ability and willingness as a basis. Successful accompaniment always includes motivational work, encouragement and the support of hope.
For manageability:It describes the extent to which people assume that they have the appropriate resources to meet the requirements. The certainty of being able to meet the requirements can only develop on the basis of the ability to act in dealing with the disease. Action here means a conscious, planned and justified activity in order to achieve a certain goal. In particular, training in the ability to act must be based on the experiences and possibilities of those affected. In addition to the complex knowledge, which is a basis for decision-making skills in partnership, the actual manual techniques must also be learned. At best, the person affected has a whole repertoire of methods and techniques that he can use in a targeted manner in the relevant situations.
To meaningfulness:Understanding and being able to carry it out are not enough to cope with a situation positively, willingness is also important. The meaningfulness / meaningfulness presents the motivational element, i.e. there is the perception that the effort is "worth the effort", the challenge is experienced as meaningful. The experience that one's own actions influence the shaping of life situations increases the significance. The patient himself becomes an active participant in the nursing process and educational activities. A link between these new experiences, self-conception and one's own basic attitudes, for example through ethical convictions, religious values or cultural orientations, should be promoted. By classifying and reflecting on your own values, new contexts of meaning arise again.
For understandability:This means whether people experience events and explanations as structured, clearly informative, consistent and thus can classify what they have experienced in their cognitive world. Information about illness, causes, influences, treatment and options and coping with everyday life (care) can serve as a basis. It is important to consider the possibilities of those affected and favorable times. Knowledge should be processed in a complex manner. Beyond purely reproducible facts, principles must be understood, knowledge must be practically applicable, up to the ability to make assessments and pass on knowledge. The more complex knowledge is processed, the more likely it is that a disease and its consequences will become a "manageable problem" rather than a threat for those affected. This requires a strong practical relevance in the transfer of knowledge and linking to existing knowledge.
Antonovsky A (1987): Unraveling the Mystery of Health. San Francisco: Jossey Bass
Federal Center for Health Education (Hrsg 2001): What keeps people healthy? Antonovsky's model of salutogenesis - status of discussion and significance. Research and Practice in Health Promotion, Volume 6. Cologne
Health literacy is a theoretical approach of the WHO (Health Literacy), it has also become better known in the German-speaking area in the last decade. Of all approaches, a comprehensive claim is formulated here, namely to have the competence to control one's own health. In developing countries this can mean being able to obtain, read and write information at all, and to understand simple interrelationships. In our part of the world, other skills are also necessary: understanding the market, selecting experts, assessing evidence-based, evaluating providers abroad, buying good-value and inexpensive products.
The example of health literacy also shows that there can be different "levels" in patient education. For some people “factual knowledge”, a few hints and tips are enough. Other people try to understand the "principles", to classify relationships. For your own actions, more knowledge also means more freedom, independence from professionals. On the other hand, this also means more effort in patient education, many patients reach this phase after years of self-experience, often through “trial and error”. On closer inspection, many skills are necessary: Assessment and decision-making, perception, weighing up risks, motivation, communication with professionals, manual skills, assumption of responsibility, the basic conviction of wanting to get well again and much more. However, there is still a way from knowing to acting.
A mature level of health literacy includes "optional action", which means that those affected can choose different options from their own skills, but they do not harm themselves. You understand the connections and have options. You can deal with complications and act well even under adverse conditions (e.g. on a trip abroad without aids). All of this could only be increased by the ability to pass this knowledge on to other affected persons in a structured, understandable and motivating manner, be it through publications or involvement in self-help groups.
Nursing-related patient education aims at different situations. Quite often the first contact for long-term care (SGB XI area) or the first orientation in the hospital are meant. Patients and relatives need information about what to expect in the hospital, they need information about upcoming procedures, about the daily routine.
The lion's share of care-related patient and family education is directed towards coping with everyday life in the case of chronic illness.
The trajectory (curve) model describes the ups and downs in coping with chronic illness, it is a course with stable and unstable phases, acute episodes, spins, crashes, or problems of the 2nd order that come to the fore (e.g. Family care, finances, drug side effects). It also describes various lines of work that must be carried out by those affected, it is about securing the household, the family, everyday life and work, compliance with medical regulations, the classification of the disease in their own life plan, etc. In addition to the medical (laboratory -) Finding, the trajectory model represents an extremely impressive and realistic (different) course. It is a good basis for patient education.
Subjective health and disease theories / culture-sensitive aspects
We consider this theoretical contribution from the health sciences to be absolutely necessary for care-related patient education. People try to explain their illness to themselves, they trace it back to previous family events, to connections of guilt, to a bad lifestyle, to fate, bad luck or even “revenge from above”. It is important for professionals to listen to these subjective patterns of interpretation; they are starting points for working with the patient / family. The question always has to be: "What do you know about the disease"? or "how did that come about (causes)".
A reference to cultural sensitivity should also be given at this point. Without knowledge of the cultural background, conversations / mediations are ineffective. It is an indictment that Germany, as the world's second most important immigration country, has hardly developed any concepts for health support for immigrants. There are hardly any approaches or material for foreign language users - although it must be clear that a mere linguistic translation of information is not enough.
This theoretical contribution from the social sciences shows that people in crisis situations seek mutual support - decades of research have confirmed this approach again and again and is also particularly important for care work. It establishes the entire family orientation / work with relatives and also the self-help movement.
This self-empowerment approach comes from critical social work and initially referred to the “liberation of the oppressed” through literacy campaigns in South America (Paolo Freire). Applied to the health system, it is about the independence of the sick from the professionals. The nursing professions would have many opportunities to enable the patient to take his fate into their own hands. However, the empowerment approach should be translated more clearly for care work.
There are two problematic aspects here:
Carers often feel like victims themselves. In order to convey reinforcement, the community of professional carers would first have to see itself as a strong force, only then can the clients be empowered.
It should also be borne in mind that sick people are suffering: they hope for help from experts, have complaints, are worried about their existence and want to be looked after. For empowerment efforts, especially with chronic illnesses, the right time must be considered. All efforts to “build up the responsible patient” are subject to a similar dilemma. Only in a few cases is the patient also a critical consumer or an informed user.
The theory of self-efficacy (Badura) has been confirmed for decades: people want to take their affairs into their own hands. This also corresponds to the statements of humanistic psychology, in which people are most motivated to realize themselves (Maslow). In an illness, everyone wants to make their own contribution to getting well.
In acute phases this is often buried (wanting to be cared for), but in a long-term perspective it is about gaining control over one's own situation (related term: control conviction).
This approach is based on the theory of self-efficacy, presented by Kanfer in German-speaking countries. However, the term self-management in health care is ambiguous, there are completely different understandings under this approach (see article Schaeffer / Haslbeck). This concept was favored by politicians and payers for many years under the aspect of cost containment (everything becomes cheaper) - there are numerous activities under the term self-management. The British health service, the NHS, presented self-management as a patient expert program for many years, but said goodbye to it years later. A basic idea was the use of affected patients in group training courses; these patients are prepared in short training courses. The approach has become known worldwide as the “Chronic Disease Self Management Program, CDSMP”, developed by K. Lorig in Stanford, initially for rheumatoid patients, now for many diagnoses of chronic diseases. There are 7 group modules, offered in the acute phase, the evaluations relate directly to the end of the course, less so in a long-term assessment. The concept is being marketed internationally with great pressure.
In terms of health education, the programs appear as short group interventions, strongly behavioral with a high level of control, behavioral plans, questions, 4-5 topics are addressed in different depths per session. The procedure is very similar to the Weight Watchers programs (although they can be successful in the medium term).
From a medical perspective, the concern of “self-management” is understandable - it is an alternative to a paternalistic doctor-patient relationship; it is about the management of the disease and its consequences. In nursing, the term is actually superfluous, the individual everyday life as a target can only be designed by oneself anyway.
Encouragement / hope
The orientation towards hope / encouragement should be recommended here as a particularly suitable concept of nursing patient education. This is very close to the issue of increasing coherence in the theory of salutogenesis.
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