21 Oct A Theory on Patient Education
I have a nurse friend who was asking around for leads to research about, “what motivates patients to participate in patient education?”
I had already started to form my own view on that, so instead of looking around for leads to articles that I didn’t know existed, I provided my own answer, founded upon conversations that I have had recently, and in the past, but also upon a recent experience I had following up with patients with diabetes who had been given an opportunity to participate in an education pilot, but who had not taken the chance.
So here it is:
In my own experience people want to learn when they sense they have a gap in understanding, and that gap is worth filling. That gap creates an “unresolved cognitive tension.” A gap is worth filling if it's immediately relevant, useful, or interesting. Our knowledge of the world has all kinds of gaps, but we may not recognize these gaps, and we generally disregard these gaps on a day-to-day basis, because in our current world of industrialization and specialization, someone else will “mind the gap.”
For example: I have a gap in understanding about how all the diabetes medicines out there actually biochemically interact with cells in my body. But it isn't immediately relevant to me, even though I am working on a project about managing type 2 diabetes, because it’s not my job to know. So I haven't explored it.
I have a general sense that there are 4 to 5 classes of medications used to manage blood sugar, and those classes of medicine work according to different biochemical mechanisms...but that’s all I know. But that’s all I need to know. For med students, we give them tests to assess their knowledge in their specialties, and those scores correlate with job prospects. That makes learning it immediately relevant to them, and needing this to help a patient makes it relevant in the long term. But I wager that the Step Test (1, 2, 3?—not sure because it’s not worth it to bother anyone else by asking, or to look into it any more deeply than beyond the basic description on the website: Low cognitive tension) is the real driving force.
Here’s an example where a gap suddenly became relevant: One day I came home to find that my 4-year-old son had a second degree burn because he had climbed up and put his hand on the hot stove. My wife had to leave so I was in charge of helping the sad boy. I knew what had caused the pain (poor boy touched a hot stove), so there was not a gap there, but there was a gap about what to do to relieve the pain.
Even though I was an Eagle Scout and had earned the first aid merit badge, I wanted to go beyond basic first aid to really help my son feel relief as soon as possible. So first I Googled it, then called my mom who is a pharmacist, then drove to the pharmacy for some topical anesthetic. The immediate pressing pain my son was feeling made acquiring information, (perhaps different from learning), immediately relevant.
To bring it closer to the origin of the nurse’s question, and to my recent qualititative research experience, let’s consider learning about diabetes. Undiagnosed people with diabetes have a gap in their knowledge. They don't know they have the gap though. It hasn’t yet caused them pain, or any physical challenges, and there are no immediate consequences…so why learn about it?
However, if someone has been diagnosed with diabetes, they no longer have the gap of not knowing about diabetes (assuming they believe the doctor, which seems to be not uncommon). There is still perhaps no immediate pain, but now that pre-diagnosis worldview of what diabetes is suddenly relatively inadequate. The cognitive gap is now made relevant by it’s personal application and someone experiences that cognitive tension. It now matters what impact diabetes can have on a person. The effort someone applies to finding a resolution to the tension is directly correlated to the believed potential impact the answers have on that person.
In my follow up calls with patients, one gentleman I spoke with believes that learning would have great potential to impact him. So he pursues requesting access to education. He called me back when I left a message asking if I could follow up on the pilot (suggesting motivation). In that call I learned that he didn’t participate because he couldn’t. I offered to connect him with another form of education, which he gladly accepted. He then called me when he received my letter with the information on other options (still motivated). He was again looking for more help to connect to education. We are sending written diabetes curriculum to his home, which I expect that he will read, cover to cover, because he has been so consistent in seeking to learn.
Why he believes that this education has potential to impact him is that he has been doing something (not sure exactly what diet/lifestyle motivation he has been trying), and it has not had the desired effect of making his blood sugar readings go down. So there is something he doesn't know about the complete picture—he is experiencing unresolved cognitive tension, a gap. He believes “education” is relevant to him because he 1) has a feedback mechanism (blood sugars) that aren't going well (he could be a perfectionist or it's just in his nature to optimize) and/or 2) he believes that there is some likelihood that he will reduce the chances of going on insulin and this is not a desired outcome (which he also mentioned).
I would venture as well that this gentleman also has little to no existing diabetes knowledge framework, or at least it is not substantial enough to know where he has questions, in order to ask them specifically. He is likely looking for a framework to help him establish a foundation of knowledge, into which he can fit his existing experience/knowledge with his medication, exercise, eating habits. Once he has that structure he can ask (if he is truly an engaged learner) specific questions that will address where his experience doesn't seem to match the provided framework.
Another gentleman I spoke with was diagnosed ~6 months ago. Between then and now, he had met with educators in the hospital, an MD, a nurse, and someone from Endocrinology. I think it's safe to assume that by the point we mailed him the letter inviting him to the education pilot that he no longer had a significant gap in his schema. The educational structure/information provided to him had resolved to the point with his existing schema/worldview that any tensions still existing were 1) less important than other life responsibilities/activities and/or 2) he had preconceptions about the learning experience that suggested a sub-optimal effort/benefit equation.
So in the case of this second patient, the question I would ask, if we were really trying to motivate someone to engage in education, is what would adequately disturb his worldview to the point that he felt it worth resolving—in other words, when he would seek learning?
But, I think this assumes the mission is to educate him. The real objective is not actually to educate…the mission is to enable behavior that decreases medical risk/cost, improves likelihood of health and wellness, and enables self-efficacy, right? Education is just one tool leading to those outcomes.
PS. Feel free to share any articles that you think might really help my nurse friend on her search.