A dialogue-based approach to patient education.

In recent years, the need for person-centered patient education has become evident. To translate this approach into practice, new theoretically and empirically sound methods and models are required. This brief communication introduces a newly developed toolkit that has shown promise in facilitating person-centered education and active involvement of patients. Two health education models constituting the underlying basis for the toolkit are also presented.

INTRODUCTION

Scholars agree that the time for person-centered care, including patient education, has come.[123] However, to implement this approach in practice, theoretically and empirically sound models and methods are needed to facilitate patient participation and dialogue in education sessions. This need guided the development of two theoretical models as well as a toolkit for group-based patient education called NExt EDucation.

A TOOLKIT FOR ACHIEVING PERSON-CENTERED PATIENT EDUCATION

The toolkit consists of 24 exercises developed to support health educators in ensuring that patients’ experiences and concerns are the center of attention in teaching sessions. This implies that patients are involved in identifying challenges and required solutions. The exercises make use of images, quotations, and “gamification” to stimulate different learning styles and preconditions for learning.[4]

The 24 exercises are grouped into four themes. The theme “Reflection and Experience” contains 12 exercises promoting patients’ ability to reflect on their personal situation; they are designed to stimulate the sharing of experiences among patients. The theme “Motivation and Goals” consists of six exercises focusing on goal setting and motivation for change. The theme “Knowledge and Learning” focuses on presenting medical knowledge in a way that matches the needs of patients, building on their knowledge and experiences. The final theme “Body and Senses” use kinesthetic and sensory inputs in different ways to stimulate the learning experiences of patients.

TWO EXAMPLES FROM THE TOOLKIT

Two exercises – “Who am I?” [Figure 1] and “Balance Cards” [Figure 2] – from the theme “Reflection and Experience” illustrate the toolkit.

Figure 1

Examples of picture cards from the exercise “Who am I”?

Figure 2

Examples of picture cards from the exercise “Balance Cards”

“Who am I?” consists of 50 picture cards intended to prompt a variety of associations. The aim of the exercise is to give patients the opportunity to get to know each other, and the cards enable patients to talk about aspects of themselves they might not otherwise mention.[4] Furthermore, the exercise can both enable patients to discover common interests and give the health educator insight into their lives. One health educator from a Danish patient education setting explained how the tool created room for patients to talk about their lives and stimulated cohesiveness within the group:

“It (using the tool) tells me about the human, not the disease. When doing that, you lay the foundation for a whole different style in the group (of patients) including cohesiveness and comfort.”

“Balance Cards” consists of 27 cards focusing on different areas that are relevant to patients with diabetes. Each card displays a picture, a title, and a quote to provide different prompts for patients.[4] The aim of the exercise is to assist patients in verbalizing the imbalances, challenges, and possibilities they experience in their daily lives with diabetes. Furthermore, the exercise can facilitate dialogue among patients that helps them identify their personal challenges and opportunities for change.[4] Diabetes affects many areas of a person's life and has far-reaching physical, psychological, social and financial consequences.[2] This exercise is meant to address some of these concerns and make it easier for patients to openly express difficult topics related to the disease.

Diabetes educators have found the “Balance Cards” helpful for assisting patients to bring up topics they might otherwise find difficult to discuss. One health educator from a Danish patient education setting expressed it in the following way:

“… (patients) sometimes get to say things that might have been more difficult without the cards. They are helped along a little because it initiates something we cannot by asking about something completely different. In that way, we gain actual knowledge on what matters to them and normally, that has not had a strong presence in the educational session”.

THEORETICAL BASIS OF THE TOOLKIT

The exercises in the toolkit are based on two theoretical health education models, “The Balancing Person” and “The Health Education Juggler.”[56] The Balancing Person describes how patients experience life with a chronic condition. The development of the model was guided by interviews and workshops with patients about the experience and challenges of living with a chronic disease. Four main challenges were identified for patients with chronic illness: Bodily infirmities related to physical changes, lowered bar related to practical limitations imposed by living with chronic illness, challenging relations related to social changes arising from the limitations of chronic illness, and changeable moods related to emotional changes.[45] These challenges were then translated into four related meta-needs that are important to address in the education process: Wholeness, clarity, timeliness, and connectedness.[5] The first meta-need, wholeness, describes the need for patient education to ensure a link to the patient's whole life, e.g. the patient is seen as a whole person and not just a person with a disease. Clarity denotes the need for health education to help patients be aware of both challenges and possibilities and where they can turn for help. Timeliness ensures that the health educator “chooses to do the right thing at the right time.” For instance, it encompasses the need for educators to pay attention to and act on patient signals during the sessions and recognize and acknowledge patients’ educational processes. The last meta-need, connectedness, expresses patients’ needs to be social and connected. Patients are able to share their experiences, find new role models or develop a sense of group identity through participating in a patient education program.[5]

The “Health Education Juggler” describes the competencies necessary for health educators to perform participatory, group-based patient education for patients with chronic illness. The model consists of four roles the health educators must be able to juggle, switching between them to ensure that group-based patient education is, in fact, participatory.[6] The four roles included in the model are the embracer, the facilitator, the translator, and the initiator. In the embracer role, a health educator brings the group together and creates a supportive environment for patients, inspiring trust and safety and showing openness, tolerance, and flexibility. In the role of facilitator, the health educator assists patients in getting an overview of the challenges they face. In this role, the educator listens and asks relevant questions that engender dialogue between patients, as well as managing and directing the group discussion as needed to ensure that it continues to be of interest of the entire group.[46] In the role of the translator, the health educator passes on medical knowledge in a way that patients find relevant to their specific situation and inspires them to take action.[4] Finally, in the initiator role, the health educator motivates patients to take action and make changes in their life, stimulating their thoughts and helping them realize the problems and solutions that are relevant to their situation.[46]

The person-centered agenda in the field of health education for patients with chronic conditions creates new demands on both health educators and patients. Dialogue tools cannot stand alone; they require patients’ active engagement in educational sessions as well as the development of adequate communication and facilitation skills among health educators.[78]

CONCLUSION

This brief communication illuminates the potential of using tools to provide person-centered patient education that addresses patients’ experiences and concerns related to their life with a chronic condition. A feasibility study of the toolkit has been conducted, and the exercises have received positive feedback from educators. The toolkit is currently being evaluated to assess whether its use promotes behavioral and psychosocial changes.