The ‘framework’ from the Royal College of Nursing, RCN (2012) summarized how and what nurses need to do to improve child and parent understanding, knowledge and management of dermatological conditions, but did not explain why nurses need to achieve these goals (RCN 2012). However, components in the RCN framework – knowledge, information and learning – were identified as common aspects of nurses’ successful eczema educational interventions of Cork et al. (2003), Grillo et al. (2006), Moore et al. (2009), Schuttelaar et al. (2010), Ersser et al. (2013) and Jackson et al. (2013). The systematic review of educational and psychological interventions for eczema, by Ersser et al. (2007) determined that few of the seven interventions examined could be compared because the methodologies used varied greatly and most studies were not robust. No theoretical framework or foundation to the studies were identified.
Chisolm et al. (2010) created a framework guided by their review of research into Health Belief, Health Behaviour and Social Cognitive Theory models, but they stated (p. 230) that ‘although AD treatment education programs can improve adherence, we do not yet know why….’. They recognized that written care-plans, follow-up appointments, discussion between the practitioner and the patient when care-plans are created were important factors in improving adherence to treatments. Fundamental to Social Cognitive Theory (SCT) is the idea that learning occurs best when the learner observes a task or skill, practises it and refines it, with the mastery providing motivation for potential behaviour changes. This has important consequences in health care where treatment and management of ongoing conditions need self-efficacy to develop (Bandura 1986, 1997). At no point were health behaviours, an important aspect of SCT, linked to patients’ or parents’ existing and newly gained knowledge about eczema. These are needed to master eczema care (Nicol & Ersser 2010). None of what is currently known about learning and knowledge was examined, with authors, concluding that future research was needed.
Schuttelaar et al. (2010) utilized SCT theory to motivate 55 patients aged 16 years and younger, to learn to control and manage eczema successfully. The nurse practitioner explained the aetiology of eczema, details about topical treatments, triggers and demonstrated application of those treatments. The role of the nurse as a motivator was recognized as an important aspect of helping participants to understand what they needed to undertake. This led to improved adherence. Follow-up appointments at 4, 8 and 12 monthly intervals helped the participants to practise what they needed to do, revisit things that were unclear and feel supported. Participants in the intervention group felt increased satisfaction with the service, compared with those who saw the dermatologist. The authors recognized limitations of a non-blinded intervention carried out in specialized, secondary care. No attempt was made to assess any knowledge gain of the participants. Behaviour changes were attributed to SCT, but no explanation was given as to why this improved the outcomes. The eczema education workshops by Grillo et al. (2006) and Moore et al. (2009) where explanation, demonstration and support featured had similar findings.
The Eczema Education Program (EEP) utilized social learning theory as the construct underpinning nurse-led eczema group education (Ersser et al. 2013, Jackson et al. 2013). Self-management, knowledge and understanding of eczema triggers, treatments and management showed statistically significant improvement. Importantly, this programme was conducted in primary care and resulted in less return visits to the general practitioner. Researchers noted limitations of the programme not having a control group, but a future randomized control trial is planned. There was also difficulty in retaining those primary care nurses who were trained especially for the EEP meaning that the expert eczema nurses assumed responsibility for the educational intervention (Ersser et al. 2013). Primary care eczema education studies prior to the EEP have not been robustly explored (Chinn et al. 2002).
What are the essential elements of successful nurse-led eczema education to be incorporated into a framework? A systematic review, by Friedman et al. (2011) on effective teaching strategies and patient education determined that those involving structured, culturally appropriate and patient-centred features improved knowledge, decreased anxiety and increased consumer satisfaction.
Nicol and Ersser (2010), de Bes et al. (2011) and Stalder et al. (2013) explored the role of the eczema nurse educator detailing the success of various educational interventions that improved patient knowledge. Successful modes of delivery included one-on-one face-to-face sessions, group workshops, eczema ‘schools’, DVDs, written information and access to support groups. However, no authors described any theoretical framework under-pinning improvement in knowledge or practical skill development.
Barbarot et al. (2013) highlighted the importance of health professionals recognizing that the giving of information alone will not help patients with long-term illness develop the knowledge and skills necessary to manage their condition. Barbarot et al. (2013) supported Cork et al. (2003), adding that mastering the treatment skills is essential for long-term management. However, no studies explained why the interventions were successful. We contend that to have a fuller understanding of effective CPE, it is necessary to identify the basic elements of the nature of knowledge, cognitive psychology and social cognitive theory and how these interplay in the learning process.
The nature of knowledge
Keeves (1997) explained the concept of knowledge and human enquiry identifying three ‘world views’, using the work of Popper and Eccles (1977). World 1 holds objects and structures created by people, such as the health systems, hospitals, universities and communities. World 2 is the world of the individual mind, the subjective and for eczema education, it is the patient and/or parent learner. World 3 contains the output of people's minds, various forms of stored knowledge, such as published health and nursing research, evidence-based nursing standards and patient-centred health information material. Learning occurs in the mind of the learner (World 2) when the learner experiences something from World 1, the real world, or gains information from World 3, either from some form of stored knowledge or through instruction from someone (Figure 1).
It is important to understand that World 3 contains much information. The mind of the learner is bombarded with information, particularly since the advent of the internet. The nurse in the CPE role has the difficult task of acting as a conduit, feeding and filtering information from World 3. Keeves (1997) emphasizes a threefold purpose in education – the transfer of knowledge, filtering and assimilating that knowledge and then developing the skills of enquiry to test the new ideas against what is known already, critically evaluating new information. This is particularly important for eczema, where there is copious misinformation available.
Kahneman (2011) has identified that World 2, where patient education occurs in the child's or parent's mind, works as two separate systems. System 1 operates automatically and quickly, whereas System 2 is more deliberate and slow, requiring more effort and mental activity. Effective learning takes place when System 2 is engaged and explains why patients cannot take information in during the often short medical consultation (Ridd & Purdy 2009). Kahneman's (2011) concept suggests that the success of any health-related education rests on recognizing that it takes time and careful explanation to help children and parents link the new information given to them about eczema with their prior knowledge. Only then can sense be made of the new knowledge related to their condition and development of the skills and confidence required to self-manage the condition occur. We contend that nurses are well placed to provide this education, having more time to undertake the task. This was recently demonstrated by (Ersser et al. 2013, Jackson et al. 2013).
Anderson (2005) and Marzano et al. (1997) identified two different kinds of knowledge, declarative and procedural, both of which require different strategies to be acquired and assimilated. Declarative knowledge is defined as the knowledge associated with facts and concepts, like the significance of an impaired skin barrier in eczema sufferers. The acquisition and assimilation of declarative knowledge requires three phases (Marzano et al. 1997, Anderson 2005). Firstly, the learner attempts to make sense of the incoming information by constructing meaning and tries to connect to what is already known. Following this ‘constructing meaning’ phase, the child/parent seeks to organize knowledge, making more connections with what they already know and consolidating their understanding of what the nurse has explained. Finally, once the knowledge is organized, it is stored ready to be retrieved for use later. For declarative knowledge, much time is spent constructing meaning.
As an example of declarative knowledge, children and parents should gain an understanding of skin function and in particular, what is happening to the skin of an eczema sufferer. The abstraction of the skin, likening eczematous skin to a brick wall with missing mortar joints, helps children and parents easily understand how skin function is compromised, how easily irritants and allergens penetrate damaged skin and why using soap compounds the problem (Cork 1997, BDNG 2012a). They readily understand why a primary goal of eczema treatment is to replace the missing and crumbling ‘mortar’ in the skin, using thick enough emollients to re-establish skin function. For CPE, it recognizes what children and parents already know about eczema and links it to what they can readily understand. It also provides an easy way of learning how emollient therapy works. Thus, the ‘brick wall’ model allows learners to construct meaning, organize their knowledge and store it in an easily retrievable manner. They can ask questions, discuss concerns and have the opportunity to work through the three phases of gaining and assimilating declarative knowledge, creating less chance to be led astray by the myriad of misinformation from media and friends. This helps explain the success of EEP by Ersser et al. (2013) and Jackson et al. (2013).
Procedural knowledge is identified as the knowledge necessary to complete practical tasks, such as applying topical treatments (Marzano et al. 1997). The first step constructs a model of the process to be learnt. Eczema nurse educators break the process down into small steps, illustrating with diagrams, creating a care-plan and then demonstrating the procedure. An effective eczema educator must also allow children and parents to feel the varying textures of the different thicknesses of emollients as cosmetic acceptability is an important factor in adherence for persons with eczema (Carr 2006, Ellis et al. 2011, Coyner & Purath 2012). The second step in acquiring procedural knowledge involves shaping the skill, recognizing how to vary the procedure according to specific needs and learning how to avoid common errors. For eczema, this involves learning to apply the emollient in a downward direction, in the direction the hairs erupt from the skin, not up and down or in circles, as is common practice (NICE 2007). It also involves the child and parent learning how to apply topical corticosteroid preparations to the reddened areas, using the validated ‘finger-tip’ method to quantify the amount to use (Long et al. 1998). Alternatively, the nurse demonstrates applying the required amount until a ‘shine’ appears on the skin (NICE 2007). Nurses, as effective patient educators, help learners become skilled in monitoring their symptoms using their senses, particularly sight and touch. Parents need to be shown how to observe and feel skin and need practice in recognizing the subtle changes that influence the ongoing treatment cycle. The third aspect of developing procedural knowledge involves internalizing the skill, practising until the skill becomes automatic (Figure 2). Children and parents need to practise until they can recognize whether the dryness of the skin needs a thick cream emollient or a greasier preparation. This is an important factor in the increased satisfaction experienced in the nurse-led educational interventions and EEP (Cork et al. 2003, Grillo et al. 2006, Moore et al. 2009, Schuttelaar et al. 2010, Ersser et al. 2013, Jackson et al. 2013).
Figure 2. A model of the instruction and feedback process in which the child and parents acquire and refine knowledge and skills, adapted from Keeves (1997, p. 2).
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The importance of instruction in both declarative and procedural knowledge
With limited instruction, children and parents have difficulty recognizing what they need to do for the long-term, especially adjusting medications and treatments. The nurse is an essential component in simplifying the myriad of complex concepts and helping children and parents develop the necessary skills.
One of the nurse's primary tasks in managing eczema (NICE 2007, RCN 2012) is patient education and the nurse provides a vital link between the healthcare provider diagnosing the condition and the children and parents, enabling improved adherence to recommendations (Cork et al. 2003, Schuttelaar et al. 2010, Ersser et al. 2013, Jackson et al. 2013). The nurse identifies the gaps in knowledge and understanding, helps children and parents assimilate their ideas and verbalize their understanding, thus creating a feedback mechanism. The nurse can review any treatment techniques children and parents have not mastered and help them develop fluency with their ideas. Fears about side effects of the topical corticosteroid preparations, which pose a challenge to nurses caring for those with eczema may also be reduced (Smith et al. 2010, Nicol 2011, Santer et al. 2013). Support by health professionals, especially expert eczema nurses, is a common theme highlighted in educational interventions and focus groups (Cork et al. 2003, Grillo et al. 2006, Moore et al. 2009, Schuttelaar et al. 2010, Smith et al. 2010, Ersser et al. 2013, Jackson et al. 2013).
Behavioural changes – Social cognitive theory (SCT)
Health behaviours in CPE result from cognitive, behavioural and environmental factors with cognition an important mediator (Figure 3). Bandura (1986) has suggested that SCT provides a model that explores the factors that determine the longevity of behavioural changes resulting in successful outcomes. SCT explains how children and parents through gaining knowledge, confidence in self-management and self-monitoring techniques and developing strategies undergo behavioural changes that allow them to persist with treatments despite the intermittent difficulties characteristic of eczema (Bandura 1986, 1997). They develop realistic outcome expectations that assist the resilience, perseverance and long-term commitment, essential factors when lengthy treatments may only produce some reduction in symptoms (Bartholomew et al. 2000). If learners believe that the task is achievable, the more likely it is that they will be motivated to try and subsequently succeed. Therefore, they are more likely to engage in emollient therapy if they have the confidence that they can do it and believe their efforts will lead to an improvement in eczema symptoms and self-efficacy as shown by Ersser et al. (2013) and Jackson et al. (2013).
Bandura (1986) identified four important sources of information relevant to behaviour change. The first is existing personal experience. The second is vicarious experience, such as when learners can observe others successfully managing. A third influencing source is verbal persuasion from others and the final one is physiological feedback. Children and their parents can be greatly reassured when they see a nurse demonstrating emollient therapy and wet wraps and are then encouraged to try it for themselves. Reassurance and encouraging feedback from a nurse as the parent builds confidence are more likely to lead to lasting behavioural changes. Lastly, witnessing the benefits of eczema reduction and the improved QOL are going to motivate the patient or parents to maintain the positive behavioural changes. The improved outcome and satisfaction of EEP can be explained using these ideas (Ersser et al. 2013, Jackson et al. 2013).
In clinical practice, nurses usually meet parents and patients at the point of their previous and existing experience, acting as role models and demonstrating the various techniques. Nurses can instil confidence that the child and parent have the capacity to succeed with the necessary treatments providing encouragement through guided practice and reassurance that the treatment will have a positive effect (Nicol & Ersser 2010). Subsequent visits provide opportunities to point out and celebrate progress made (Figure 3). By motivating and reinforcing the procedures when making time for supervised practice, parents and children gradually develop the skills to undertake these complex treatment tasks confidently. Nurses also motivate and support children and parents during setbacks when triggers or infection may exacerbate eczema (Ersser et al. 2007, 2013, Schuttelaar et al. 2010, de Bes et al. 2011, Jackson et al. 2013). This assists children and parents to more easily accept the responsibility of making the necessary life-style changes for successful long-term management (Bandura 1986).
The goals of CPE in eczema
To summarize, for the framework, the goals of eczema CPE are to help children with eczema and their parents to:
- gain the knowledge necessary to understand the condition.
- quantify and clarify terms commonly used in eczema management.
- simplify, filter, organize and target the information that is most important to the individual's needs, consistent with the healthcare provider's recommendations.
- understand the eczema care-plan created for them.
- explain, demonstrate and assist in learning how to undertake these processes.
- learn how to monitor symptoms, adjusting treatments in a feedback cycle, as the severity of the condition varies.
- develop the sensitivity needed to discern the symptom variation and the subtle changes in the skin.
- develop, practise and fine-tune the skills needed to administer treatments.
- change their behaviours in ways necessary for long-term management.
We argue that a framework based on an understanding of how knowledge is built on the individual's experience of the world, an understanding of the importance of instruction in both declarative and procedural knowledge and an understanding of what motivates children and parents to make the necessary life-style changes is the next essential step towards improving CPE in eczema management. Such a framework will help those seeking to develop their skills in CPE and, at the same time, complement the various standards of CPE in the eczema guidelines and provide a structure to facilitate research (NICE 2007, RCPCH 2011, RCN 2012).
The proposed framework
We have argued that any successful CPE programme should be founded on an understanding of how the learner in World 2 interacts with Worlds 1 and 3 to gain knowledge. Also, we argue that CPE involves helping the learners understand their experiences from World 1, the real world and dealing with the vast body of knowledge from World 3. Nurses act as a conduit of information from World 3 providing the learners with the skills needed to assess new information. It is further suggested that real learning can only take place when the learner has time to engage in the depth of mental activity necessary. This has been an important argument for nurses to take on the responsibility for CPE, as doctors have too little time for effective CPE. An important distinction between declarative and procedural knowledge has been outlined. It follows that for children and parents to develop the necessary practical skills, demonstration and practice are vital.
The nurse's role in motivating both children and parents to adhere to the treatments provides educational support, enabling children and parents to undertake the treatments with confidence, knowing that doing so will lead to improved outcomes (Jackson et al. 2013). This also enables the long-term behavioural changes. This suggests a multi-layered approach, where the nurse, in clinical practice, attends to all of these elements (Figure 4). It shows how effective CPE should be based on an understanding of how learning takes place, the role of the expert instructor in interpreting and filtering and in helping learners to gain both declarative and procedural knowledge. At the same time, CPE demonstrates modelling practices that will lead to the necessary behavioural and lifestyle changes. Like any model, this framework needs to be tested and revised.
Figure 4. A Framework for Nurse-led intervention for the education children with eczema and their parents, adapted from Keeves (1997, p. 2).
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