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>Source: Holmes & Rahe, 1967.<
> <
>APPENDIX C<
><
>APPROACHES TO PATIENT EDUCATION<
><
>Before trying to teach a patient about the dialysis regimen, it is important to assess the patient?s level of learning. Different people learn in different ways! Some learn simply by being told, others by watching television, still others by listening to the radio. Very few learn by reading as very few people are readers. Some patients would rather a staff member sit and explain something and then have an opportunity to ask questions while others want staff to hand them a pamphlet, give them time to read it, then return later for a question and answer session. <
><
>Many language barriers exist that present a special challenge in educating patients who speak little or no English. Remember that family is not a preferred choice for the provision of medical translation services. Pamphlets and resources in languages other than English can be obtained by contacting one of the kidney organizations included in the resources in Appendix G.<
><
>Even though they may speak English fluently, a large number of Americans have a low literacy level. The average reading level is between eight and ninth grade for the average adult American. Socio-economic status is linked to literacy with one-half to one-third of welfare recipients performing at the lowest literacy levels. Age is also linked to literacy with 44% of those 65 and over in the lowest literacy level. People who are non-readers or poor readers generally try to hide it. The burden is upon the health care professional to assess each patient?s status and respond with education that the patient can understand. This is especially true when dealing with a patient in an Intensive Intervention. Assessing learning levels can be done by asking a few questions and by making a few observations.<
><
>What is the patient?s level of education or functional competency level? What is (or was) the patient?s profession or skill? Is this a profession that requires a lot of learning of new skills and problem solving? Does the patient read during dialysis or watch television? Does the patient ask more advanced questions (?What is my URR this month??) or simpler questions (?How long do I have to keep doing this dialysis stuff??)? When explaining something to the patient, does it have to be repeated several times before the patient grasps the concept? Most importantly, does the patient even ask questions or does s/he simply accept whatever staff says? Does the patient always direct you to give instructions to a spouse, child or friend? These and many other observations can give one an idea of the patient?s learning level and how s/he problem solves, which may indicate the best medium for teaching.<
><
>It is safe to say that new techniques will be needed if the usual patient education used in the facility has failed to achieve the desired results. Don?t assume that a non-compliant patient is just choosing to ignore what has been said. Consider first that the patient truly does not understand.<
><
>References are included for resource books on educating patients. (Appendix G)<
> <
>APPENDIX D<
>SAMPLE LETTERS<
><
>Note: these letters are intended as samples and do not have to be copied word for word. It is best for clinic staff to write their own personalized letters that represent a similar tone and mood, but that contain similar information. Be careful to keep the reading level low. <
><
>FIRST LETTER OF CONCERN:<
><
>Date <
><
>Name and address of patient<
><
>Dear _______, <
> <
>We the staff at __________ Dialysis Clinic want all our patients to be as healthy and strong as possible. This is why we work hard and plan carefully for each patient. The plan that we wrote with your help or input was intended to help you to have as long and healthy a life as possible. For this reason we have a treatment plan that we believe will do this.<
> <
>We have a problem though. You are not ______________________________. In order for the plan to work you need to_____________________________________. If there is anything that is keeping you from _________________________, we want to know about it. We will work with you to solve any problem that may keep you from reaching your goal of a long and healthy life.<
> <
>Please stop by and visit with the social worker, _____________________, if there are any problems we can help you with. You can see the nurse, ___________________, if there is something about dialysis you don?t like or don?t understand.<
> <
>Even if you can?t think of anything that could be a problem, stop and see either of us anyway because we would like to talk about your plan of care for a long and healthy life.<
> <
>See you soon! <
> <
>Sincerely,<
><
><
>Social Worker <
><
>Nurse<
><
><
><
> <
>SECOND LETTER OF CONCERN:<
><
>[Note: Before sending this letter be sure to take extenuating circumstances, such as riding the city bus to get to and from dialysis, into account.]<
><
>Date<
><
>Patient?s name and address<
><
><
>Dear _______,<
> <
>Recently we wrote you a letter and asked you to talk to our nurse or social worker about the problem of ____________________________________. The problem still continues. <
><
>We want to do everything possible to help you have a long and healthy life, but to achieve this you would need to ___________________________________________.<
> <
>If you continue to______________________, we may have to take strong measures to help you help yourself. We do not want to do this, but will be forced to because of the problems your actions create for our clinic. WE WILL HAVE TO CHANGE YOUR TIME OF DIALYSIS TO ANOTHER TIME ? ANOTHER DAY AND ANOTHER HOUR THAT WILL CREATE FEWER PROBLEMS IN THE CLINIC. This could be harder on you so please come in and help us work out another solution.<
> <
>Also, along with changing your shift time WE ARE GOING TO WAIT UNTIL YOU ACTUALLY SHOW UP AT THE CLINIC BEFORE WE SET UP YOUR MACHINE. THIS MEANS YOU MAY HAVE TO WAIT AS LONG AS A HALF HOUR AFTER YOU GET HERE BEFORE YOU START DIALYSIS. IF YOUR TREATMENT RUNS LONGER THAN THE TIME OUR CLINIC CLOSES, OR WHEN ANOTHER SHIFT IS SCHEDULED, YOUR TREATMENT WILL BE CUT SHORT.<
> <
>We really do not want to do any of this and would rather have you ______________ all the time. Please come in and talk to me so we can work this all out.<
><
><
> <
>Sincerely,<
><
> <
>Doctor <
> <
>APPENDIX E<
><
>INTENSIVE INTERVENTION TECHNIQUES<
><
>1. Personalizing the Treatment Plan<
><
>Treatment Plans that include only medical objectives are often very impersonal to patients. A Treatment Plan can be used to set personal as well as medical goals. A patient who has always wanted to see Alaska can include this in the treatment plan. Every time the patient is compliant s/he can reward himself or herself by setting aside a dollar for the ?See Alaska Fund.? Including familial goals in the Treatment Plan could be helpful. ?Take a walk with my wife once a week? is certainly an appropriate personal goal that can find a meaningful place in the Treatment Plan and achieve a medical goal as well.<
><
>2. Teaching by telling stories<
><
>Many patients will listen to a story before they will
listen to a lecture. Telling patients a story about another patient who had a hard time with compliance but managed to overcome it could be very helpful. It is best to use stories that are true without using a patient?s name or stories that are a composite of several patients.<
><
>3. Teaching through appropriate self-disclosure<
><
>Self-disclosure can be a very effective teaching tool but must be used carefully. The staff member must take care not to ?unload? on a patient. Sharing a personal experience with a patient on problems with compliance could be a meaningful learning experience. Staff members who used to smoke or who have lost a lot of weight can share how they overcame those problems.<
><
>4. Recounting a famous person who overcame obstacles<
><
>History is full of examples of people who had handicaps and achieved a lot or persons who overcame great obstacles to achieve their goals. Some patients have personal heroes and may be encouraged to learn that they overcame problems as well.<
><
>5. Behavior Modification Techniques<
><
>Behavior modification can be an excellent means of changing non-compliant behavior. If there is a staff member who is familiar with contingency management, positive and negative reinforcement, token and social reinforcement, then it can be used effectively. However, learning the techniques takes years of training and using it incorrectly could be a waste of time.<
><
><
><
> <
>INTENSIVE INTERVENTION TECHNIQUES (CONTINUED)<
><
>6. Cognitive Restructuring<
><
>Cognitive restructuring involves basically helping a patient change his or her mind about a situation. This involves changing faulty thinking, stopping thoughts before they escalate, replacing thought associations, and other such techniques. Like behavior modification, cognitive restructuring is an excellent tool in the hands of a skilled clinician. However, if there is no one on staff already trained in this area, learning while doing is not a good idea.<
><
>7. Spiritual Interventions<
> <
>Referring to great figures in the Bible or other spiritual leaders can be a very effective way of helping patients become compliant. A good example is a man by the name of Hezekiah in the Bible who was about to die but was granted a few extra years of life. Dialysis can be seen as being granted a few extra years of life rather than as a burden of dietary restrictions and disrupted schedules. Assistance may be offered in accessing a spiritual support system. Encouragement can be given to the patient to interact with church groups or friends. <
><
>8. Reasons to Live<
><
>The dialysis patient could be reminded that dialysis can be seen as a gift that allows us a little more time to live. Doing something with our lives is a worthy goal for all of us, but for the dialysis patient it is especially meaningful. Patients can be told, ?You have been kept alive to do something. Perhaps it involves your family?? The book ?Reasons to Live? by Amy Hempel is a delightful collection of stories about people who faced death and chose to live instead. <
><
>9. Mobilizing Your Social Support System <
><
>A very effective way of influencing people to discontinue an undesirable behavior is to get their family and friends to help them. Patients can be taught ways that family and friends can be a resource to them in changing their behavior.<
><
>10. Shall we Talk Funerals?<
><
>This technique is listed last for a reason. This is a ?last-ditch effort? which has been found helpful in extreme cases. This technique consists of telling the patient something like ?Okay, I see that you are not going to do this compliance thing. It is your right to die with dignity. We will do what we can to make you comfortable. The doctor will prescribe pain medicine for you if you need it. It is better if you try to make funeral arrangements now so you will not leave a financial burden on your family. Shall we try to make some plans now?? This can be seen as cruel by some patients (and even staff) so it must be used only as a final resort and then only very carefully!<
> <
> <
>APPENDIX F<
>Stages of Readiness Theory<
><
>1. Pre-contemplative: not aware or not considering a change<
><
>2. Contemplative: thinking about a change, but not taking action<
><
>3. Action: has made behavior change and is practicing it<
><
>4. Maintenance: retaining the behavior via reinforcement or learning<
><
>5. Termination: the end of the intervention; the behavior is a part of life and is no longer seen as a change that needs attention or reinforcement<
><
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> Source: Schilling McCann, ?Patient Teaching Resource Manual.?<
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> <
>APPENDIX G <
><
>RESOURCES AND REFERENCES<
><
>American Association of Kidney Patients Renalife. A patient magazine available from AAKP.<
><
>American Association of Kidney Patients ?Patient Plan ? Phases 1 through 4?<
><
>For Patients Only. A patient magazine available from Dialysis Incorporated Publishing.<
><
>Kidney School, Life Options www:kidneyschool.org<
><
>Funnell, M.M., ?Helping Patients Take Charge of Their Chronic Illnesses,? Family Practice Management, March, 2000.<
><
>Holmes, T. & Rahe, R. ?Holmes-Rahe Social Readjustment Rating Scale,? Journal of Psychosomatic Research. Volume II, 1967.<
><
>Lancaster, L. E.(editor), ANNA Core Curriculum for Nephrology Nursing, 3rd Edition, American Nephrology Nurses? Association, 1995.<
><
>Renal Physicians Association & American Society of Nephrology, Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis. Washington, D.C., Fe
uary, 2000.<
><
>Schilling McCann, J.A. (publisher), Patient Teaching Reference Manual. Springhouse, <
>PA.: Springhouse Publishers, 2002.<
><
>C. Doak, L. Doak & J. Root, Teaching Patients With Low Literacy Skills, 2nd edition. J.B. Lippincott Company, Philadelphia,1996.<
><
. deSouza, Handbook of Creative Approaches to Patient Compliance; A Guide To Assist Renal Dietitians Working with Dialysis Patients. Professional Nutrition Services, Pem
oke Pines, FL, 2001.<
><
>Teschan, P.E. "The Health Assurance Coaching Model for Chronic Renal Disease Management." Advances in Renal Replacement Therapy, Vol 9, No 3 (July, 2002): pp. 2230-223.<
><
><
>The ESRD Network of Texas, Inc. has provided to each unit and available for purchase at a nominal price two patient education videos on Dialysis Adequacy and Vascular Access.<
><
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> <
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>
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patient
Joined: 29 Oct 2002
Posts: 137
Posted: Mon Jul 21, 2003 4:21 am Post subject: Ramiro Valdez
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One would think this man has more to do than to write a bunch of crap all the time, but I have seen numerous articles written by this man. He should be more busy with trying to keep the patients in Texas in their clinics than constantly writing paranoid articles for the nephrology rags.
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Respect
Joined: 21 Jul 2003
Posts: 1
Posted: Mon Jul 21, 2003 4:55 am Post subject: This is only an employee
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You may not like the writings and the fact that they were not followed in this case. <
>But Dr. Valdez is only an employee of the Network and is only doing his job.<
>The failings are the ESRD NETWORK workings as a whole, and not just one individual. I may not agree with an action,
I may be naive, but this isnt fair. He had a job to do and you do what your told to do perhaps.<
>The failings are the government and why this course of action was not taken with our patient.<
><
><
>Arlene
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aprnjam
Joined: 28 Apr 2003
Posts: 85
Posted: Mon Jul 21, 2003 2:53 pm Post subject: Re: This is only an employee
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I agree with Arlene, often you must do what your employer wants you to do. In the government, each document is reviewed at least 10 times, and changed, before it is released to the public. What initially started out to be Dr. Valdez's work, may at the end, be a product of 10 different reviewer's/editor's. He still deserves the respect of his profession. We all do what our employer wants or we will be looking for other jobs.
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patientwife
Joined: 18 Jul 2003
Posts: 47
Posted: Sun Jul 27, 2003 2:08 pm Post subject: Intervention With The Non-Compliant Patient Guide
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I, too, agree with Arlene's premise. Personally, I find the Guide to be sound. Problems are (1) lack of implementation of guides that are so well written, and (2) lack of oversight by government to ensure "compliance" of guides by Networks and dialysis units.<
><
>When my husband became a dialysis patient, he shared the facility's Patient's Handbook with me. I read it thoroughly. Comment to my husband was, "If they do what they say they will do, you are in a good program".<
>Needless to say, I learned that the guides were just on paper.
