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• W4367677534 abstract "Peritoneal Dialysis Education in 360Gustavo Moretta MD 1, Susana Marcos RN 2, Rosana Chaud MD 3, 4, Carmen Arias Minaya RN 5, Jose Divino MD 6San Andrés University, Buenos Aires Argentine1 4; Argentine Society of Nephrological Nursing 2; FISSAL Comprehensive health insurance, Perú 3, LACDD 4, Karolinka Institutet ,Swedan.6 Summary Kidney replacement therapy (KRT) may present restrictions on a patient’s lifestyle. The patient with chronic kidney disease (CKD) must overcome numerous barriers in order to survive; among them, the capacity to discern which KRT is the best choice, allowing a smoother adaptation to the new life situation. Home KRT such as peritoneal dialysis (PD) involve patients and/or their caregivers performing all required PD technique procedures with a distant daily support of a multidisciplinary team or clinical staff. Moreover, they must also know the possible complications and their management, adapting to the policies and procedures of the health system where they belong to.The educational act becomes the central axis of this type of treatment whereas the treatment should be tailored to each patient’s individual needs and lifestyle. This independence may sometimes, unfortunately, lead to poor compliance and its possible consequences. Several authors have demonstrated the relationship of the relative risk of infectious complications by comparing patients who had a more detailed PD bag exchange protocol procedures with those who did not.(1)(2)The definition of education as the central axis of therapy is not a minor issue, because we are not talking about learning a succession of technical steps but about the development of skills that must be adapted to each person and to each health system.The educational axis has a facilitator, an apprentice and between them, the teaching materials. missing summary of other chaptersThis chapter aims to bring the education sciences closer to the health workers. In order to do so, we will review the educational content that PD patients must learn with a focus on skills development and the evaluation of lessons learned, training of facilitators (doctors and nurses) and their responsibilities, evaluation of educational programs and a proposal design for these programs as well as the health authorities responsibilities. We will finally review some PD learning experiences in Latin America and the world.This chapter aims to bring education science closer to health workers, by reviewing the PD educational content that patients must learn. The focus will be on (I) skills development and the evaluation of learning, (II) the importance of the evaluation of PD educational programs, (III) Human resources training (doctors and nurses) and their responsibilities, and (IV) review of some PD learning experiences in Latin America. I- Curriculum content and learnings evaluation of PD patients educational programs. The International Society of Peritoneal Dialysis (ISPD) has published two recommendations related to PD patient training (3)(4). They mention a number of factors that influence patient training outcomes; including facilitator-patient relationship, patient experience and knowledge as well as educational methods such as protocols, time, frequency of training, environment and training place (5). While these guidelines together provide useful training recommendations, the training evaluation methods are not based on the acquisition of competencies and there is no solid evidence that instituting these interventions leads to reduced rates of peritonitis or domain of other complications. [1]Nor has a formal assessment been made of how well these guidelines have been implemented in clinical practice or if they are performed, how much they have contributed to the clinical results obtained (6).Regarding the curriculum, the ISPD guidelines recommend a well-developed PD training content program based on adult learning theory, a technique reported to produce a considerable increase in memory (7). However, there have been very few studies evaluating the effect of the introduction of PD training programs based on adult learning theory.The study representing the strongest evidence supporting the ISPD training guidelines recommendations is that of Hall et col (8). who published an evaluation of a PD training curriculum based on adult, multicenter, non-randomized cluster training theory involving 620 DP patients. This curriculum was structured by learning levels, from lowest to highest, including memory, concept, principle, judgment/decision, problem solving and demonstration. Patients trained by a curriculum based on adult learning theory (n=246) vs conventional training programs (n=374) showed lower peritonitis rates and increased interval between peritonitis episodes, over a 24-month follow-up period. However, these results were not statistically significant and their statistical analysis has been questioned. The conventional PD training curriculum and plan were not adequately described and further clinical and research effort is required in this area before firm recommendations can be made.The teacher has an essential role in adult education as a facilitator of the apprentice’s development of mental structures, so that the apprentice is able to build increasingly complex learnings, so the action of the facilitator is that of a guide or tutor.Gadola et col (9) introduced, in Uruguay, a new PD educational program based om the adult learning theory emphasizing the training content focused on CKD and KRT modalities, basic PD mechanisms, clean and sterile concepts, hand washing, peritoneal solutions and supplies, bag exchanges, PD adequacy and timing, problem solving, nutrition, CKD complications and pharmacological treatment. Peritonitis rates decreased significantly after 24 months of follow-up. It was a retrospective design study with historical controls that led to the possibility of bias. Both studies refer to adult learning but do not describe the progress of structural learning or how to evaluate it or the characteristics of the educator Training, as Paul Freire would say, is not the mechanical activation of human skills to achieve some performance (10). It is rather a critical exercise, which empowers, breaks free and leads to autonomy. Patients' learning capacity varies and flexible methods are required. There are patients with mental disabilities, low literacy levels, poor visual acuity, cultural diversity, different native language, advanced age or pediatrics. This is the same situation faced by any teacher in daily life, with a unique aggravation that is the risk of life and the fears that it entails. So the patient needs to learn things (knowledge) that are really meaningful to his/her life at that moment and also capable of internalizing them. Taking Perkins' concepts (11) is important to make visible the two deficiencies that can be applied to the DP teaching method, fragile knowledge and poor thinking. We refer to fragile knowledge when patients do not remember or actively use much of what they have supposedly learned. We encompass in this concept forgotten knowledge (If the patient will remember the taught facts and skills, the clinical results would improve), inert knowledge (for example, many PD training programs are initiated by explaining the function of the normal kidney to a person who no longer has any kidney function left, or delivering manuals with difficult medical terms that the patient will not require) and naive knowledge, (naive theories or stereotypes, for example, if one could not finish schooling , one will have difficulty in learning) and finally ritual knowledge, (perhaps the common, for example, the so-called step by step, which only allows one to fine mechanical solutions to the patients without generating a significant apprenticeship). In terms of thinking, to think about what is learned and the active use of what was learned is the goal of education. Although repetition helps memorize, it's not as useful as other strategies that help you think. Many patients now spend one or two training days watching the nurse washing hands, or washing their own hands, without reflecting on the quality of the water they are going to use at home or the reason why they should dry properly the hands in order to avoid wet contamination. Our workouts are not designed for the patient to think or be autonomousSeveral studies, such as Dong et al (2) which observed 130 incidents PD patients, reported that after 6 months almost half of them did not wash their hands, did not check the expiration date of the PD bag or leaks and 10% did not wear a cap or face mask. An Italian study by Russo et al. (1) demonstrated that after an average of 33 months in PD, a new training was needed for 47% of patients. Several teaching tools have been applied to improve PD training experiences, since Kennedy et al.(12) utilized dolls as a tool; among them, animations, visual images, audio tapes, online courses. Everyone repeats the same educational experience based on repeating what is done in the Institutions, without searching for an educational method where one has to think. Learning is a long-lasting change in conduct or ability to behave in a certain way and is the result of practice or other forms of experience. People learn when they acquire the ability to do something different. At the same time, we must remember that learning is inferential. We do not observe learning directly, but through its products or results. Learning is evaluated based on what people say, write, and do. This point is crucial for assessing patient competencies in PD.However, we should add that learning involves a change in the ability to behave in a certain way, as people often learn skills, knowledge, beliefs, or behaviors without demonstrating it at the time of learning. Adults learn differently. A practical example may be the use of a new phone. How many people read the manual for use? One usually starts using it. The adult learns from the experience. The adult is a subject developed on a physical, psychological, economic, anthropological and social level, capable of proceeding autonomously in the society in which he lives and to define the objectives to be achieved. This allows to distinguish, conceptualize, design and develop an andragogic fact or process in the field of education. Andragogy (from Greek ἀνήρ man and ἀγωγή guide or driving) is the set of teaching techniques intended to educate adults.(13) Several theories explain how adult learning occurs, one of them is constructivism and the way to evaluate what can be learned is through the development of competencies. Constructivism states that apprentices develop their own comprehension of knowledge and skills. In the basic principles of the constructivism, it states that apprentices are more capable to remember information if the constructions contain a personal meaning to them.The goal of adult education then involves the acquisition of knowledge, the development of skills and the ability to apply these resources, in an appropriate manner, to each one of the situations arising in the daily life. An adult properly trained in the use of a peritoneal dialysis device should have the appropriate competence to decide the physical space where to perform the dialysis procedure safely and to change whenever necessary.Therefore, educational programs for patients admitted to peritoneal dialysis require education focused on the development of competencies. Competencies are comprehensive actions taken, with suitability and commitment, against activities and problems in the context integrating know-how (attitudes and values), know-knowing (concepts and theories) and know-how (procedures) into a perspective of continuous improvement.(14)Learning is meaningful when the content is related in a non-arbitrary and substantial manner (not literally) to what the learner already knows. A non-arbitrary relationship should be understood as a concept, in which the ideas are related to some existing aspect, specifically relevant to the cognitive structure of the learner, such as an image, a significant symbol, a concept, or a proposition. An example of the daily practice of a patient being PD training will be used to explain it. Usually in the curriculum, diffusion processes that explain to the patient the removal of the toxins from the blood, should be taught. For this purpose, graphs of two buckets are used separately where in one appears round figures, representing one toxin (for example, urea or creatinine) in greater amount (concentration) migrating to the other bucket containing a smaller amount (concentration) of the toxin. The same knowledge can be applied with a “thinking” experiment. The patient is asked to place a tea infusion bag in a cup of hot water and tell us what's going on. Why do you think it changes the color of the water in the cup? How much time does it take to change the color tone? Does this phenomenon seem important for you? Educational activity has been transformed into an experience based on patient’s prior knowledge, allowing him to infer new knowledge to be applied to his health situation. In order to remove toxins, it is necessary to fulfill the prescribed length of time that the PD solution will dwell in the peritoneal cavity.An important task in a teaching sequence is to determine the problem to be addressed, what can be done in a general fashion and then, with the apprentices, to accomplish it in a specific environment. Here lies one of the main features of the competency model, that is, the training is carried out by addressing real problems with meaning and challenge, because that is precisely what a competency means: it is a comprehensive action to identify, interpret, argue and solve certain contextual problems.(15) Taking these concepts into account and with a self-criticism view of the PD educational programs, the patient-apprentice should be trained at home, in his context, where he will daily perform the dialysis procedure; however, the patient is usually trained at the Dialysis center with its hospitable structure, far away from the reality the patient will face at home.Evaluation is a fundamental element in the learning-teaching process, coordinating, regulating and guiding. Understood as a process, it is immersed in learning and teaching. Therefore, the evaluation process is part of any didactic approach and an integral element of the curriculum design, having an increasingly systematic and scientific approach of all elements involved in the learning and teaching processes: educator, apprentice, methodology, contexts, etc. Just as one has to think, plan and design the teaching activity, one should also think, plan and design the performance of the evaluation, with everything that involves time dedication, resource forecasting, time setting, decision on methodology and strategies, selection of instruments. (16) The guidelines or parameters explaining the competency and allowing evaluation according to the context, present or future, are the performance criteria determining when the person’s performance is adequate in certain areas of the learning/training. In order to evaluate these criteria, it is necessary to establish concrete and tangible evidence of what is being learnt of a competency. Evidence evaluation is based on established criteria, and it is necessary to evaluate them as a whole. For each criterion, indicators are established for each level of knowledge and thereby allowing its evaluation. The indicators are signs that show the level in which a competency has developed based on these criteria. Weighting consists in assigning a quantitative value to criteria and indicators in relation to their degree of contribution to the value of the competency. Competencies are usually evaluated within a quantitative range of 0% and 100%; any scale can be applied. In order to evaluate, a percentage is assigned to each one of the criteria taken into account when evaluating one competency, according with one or more evidences. It is necessary to compare the criteria among themselves and, then, for each individual criterion, to compare the indicators in order to determine its degree of relevance in the evaluation of the competency. Understanding the different items to be considered in the competency evaluation, it is important to create an instrument whose main purpose is to share the criteria to attain the learning tasks, and their evaluation among the apprentices (patients) and the educators. This task roadmap, which will be called Rubric, describe the expectations, shared by the apprentice and educator, about one or several organized activities with different levels of accomplishment: from the least acceptable resolution to the unanimous one, from the most insufficient to the excellent. The Rubric is a powerful tool to evaluate any type of task, but its value should be especially emphasized to evaluate authentic tasks, real life tasks. It manifests itself as an ideal instrument for evaluating competencies, as it allows to analyze the complex tasks, generating a graduation starting from the simplest one to the most complex task. The Rubric is an instrument that, from the start and throughout the process, allows to share the criteria which will be applied to evaluate progress in a framework of formative and continuous evaluation. Furthermore, it reduces the subjectivity of the evaluation and facilitates different educators to coordinate and share the evaluation criteria, allows the apprentice to monitor his own activity, self-assess and promote responsibility for learning. The use of the Rubric facilitates almost immediate feedback, as it concedes substantial response time reduction by offering quantitative and qualitative results based on previously known standards for the development of the task. Use of Rubrics in Peritoneal Dialysis.Table No. 1 shows an example of a Rubric for the evaluation of the learnings. The final results will enable to classify PD learnings in initial, basic, autonomous or strategic according to the score achieved.Its design established two domains of knowledge, patient’s dialysis safety and CKD management by the patient; each domain contains two competencies to be developed.The first domain requires the development of biosecurity and connectology management whereas CKD requires management of complications associated with the technique or the chronic disease itself as well as the correct use of the local health system. For each competency, criteria have been established representing the tasks learned and the evidence of their learning. Each criterion is weighted on a scale in relation to its performance importance. For example, the domain of competence in the management of biosecurity has as its axis of procedure that the patient understands and relates biosecurity with hygiene procedures that will be carried out in his home and with the PD device. The criteria for learning vary from the least to the most (from 1 to 4). Understanding that the criterion is evidenced by the health team, during the home visit, observing the correct actions of the apprentice. For example, perform hand washing correctly, recognize where to place dialysis material, maintain a logical and comfortable order, and do not contaminate by touch. The following tables (2,3,4,5) show domains, criteria, and evidence that they would be evaluated in a PD patient training program. The Evaluation Rubric is shown in Table 1. II- Evaluation of educational programs on Peritoneal Dialysis. Education for patients with various chronic diseases is a challenge for health systems. Diseases such as hypertension, diabetes, obesity and CKD require educational programs provided by the health team so that people can develop skills or change behaviors. These non-formal adult education programs require training of their teachers in pedagogy knowledge and the evaluation of educational programs as well as their results. But the biggest problem lies in the quality of educational programs and their correct evaluation. Three core principles guide the planning, implementation and evaluation activities of patient education programs. The first principle is that the program should be based on scientific evidence, including epidemiological and clinical studies. The second principle is that it should use effective communication strategies and appropriate teaching material to reach the selected recipients and finally the evaluation should be an integral component of the planning and implementation of the program and should be used as part of an iterative process of re-planning and improvement of the program's activities (17). Program evaluation is conceived as the process of measuring, comparing and issuing a value judgment on the achievements achieved, through the application of methodological schemes that ensure the reliability of the processes and the objectivity of the information obtained. The evaluation of educational programs has existed for about forty years as a scientific discipline. A Program is a systematic plan designed by the educator in the service of educational goals. The educator plans his or her educational action for the apprentice or group, setting goals, selecting means, designing the right conditions and establishing criteria and valuation guidelines.(18) The characteristics of an educational program can be seen in table-6According to Stufflebeam and Shinkfield, evaluation should be considered a complex but unavoidable process(19). One of the most conceptually powerful aspects is that the evaluation recognizes the action plan proposed by a program as a working hypothesis. From this perspective, the evaluation reconstructs the expected causal relationships in key activities to products, from intermediate objectives (effects) to final objectives (impact). For example, the training of hand washing necessary in PD is an activity whose product is the prevention of touch-related infections, with intermediate objectives (lower gram + peritonitis rates) and final goals (better PD technique survival) Thus, the design of the evaluation and the committed activities aim to put at the center of the analysis the focal problem to which the program seeks to solve and reconstruct the changes in those factors that have a more decisive impact on the resolution problem. One of the focal problems to face is performing patient training based on their safety and not on repetitive steps. The evaluation should be conceived as a process of learning management, where the assessment based on pre-specified criteria and information technically designed, collected and organized, integrating the educational processes in order to facilitate the making of improvement decisions, by the patient. (20)The evaluation presents as components; the contents, the information to be collected, its assessment and the purpose of it. In the evaluation of an educational program we must keep in mind certain elements related to the program and with the evaluation itself. In relation to the program, it is important to evaluate its components, objectives and goals, content, media, together with its implementation and development process. The evaluation should give rise to consequences, which can be theoretical, practical, methodological and, above all, educational; both on the educational content and on the program itself and its facilitators. In reference to the methodology to be used, the technical quality of the program's own evaluation design is essential. Regardless of the evaluative model chosen, any minimal planning should establish the activities to be evaluated, set the evaluation criteria, choose strategies for obtaining and analyze information, and then make decisions from it. Evaluation requires certain stages in terms of the program itself, its implementation and the analysis of its results. Step 1: Evaluation of the program as such: It is the most important evaluation activity both because it is the first and basis of all others. Its content encompasses the program as a whole, and above all, for its great contributions to the improvement and optimization of the program even before it is launched. It aims to establish the technical quality of the program, its practical feasibility and its evaluability. Its function is basically formative, it makes in advance the improvement decisions that can raise the potential of the program. As a methodology for evaluation, it may require analysis of the content of documents and the judgment of multidisciplinary experts (methodological, scientific, technical, pedagogical).The evaluation should collect data on the basic structure of the program, its formulation and the relationship to the needs, gaps, demands and expectations of the recipients. (patients, physicians, nurses, nutritionists, social workers). The evaluation, generally, enables, formative decisions making (pre-improvement, staff training e.g.) and also, in extreme cases, summative decisions making (withdrawal of the program due to lack of resources). The required criteria are observed in table-7.The diversity of PD programs is high, but there are several factors in common. One is that it rests in the infirmary when it is necessary to participate the entire health team and the other is that the training of the staff in adult education methods (Andragogy) is low, basically empirical and absent in most of the curricular contents of the training of nephrologists and nurses. In general, institutions do not give sufficiency of the supports, means and resources, in particular on the training, involvement and commitment of the actors and others involved. A common view throughout Latin America is the variety in quantity and quality of allocated hours of resources both doctors and nurses and the effective hours dedicated to patient education. There are countries where the nephrologist is not necessary for the management of the peritoneal dialysis program, often related to lack of resources, but in the same countries if their presence is required for hemodialysis. The feasibility of the program is largely related to the continuity in time of its participants; when a change is generated by high staff turnover it reveals a weakness of the program, by not having a training system for the new personnel ,which carries risks for patients. Step 2: Evaluation of the program implementation process.This moment aims to facilitate the timely improvement in decisions making and accumulate information to be introduced into future editions of the program. Its function is basically formative. Information on intermediate results and unplanned effects is key to the methodology. It can be done through observation, dialogues, interviews with facilitators, analysis of tasks, intermediate training tests of the team and subsequent analysis of the information. The criteria are compliance, institutional coherence and satisfaction of those involved. For example, the number of average training hours received by patients is considered a compliance criterion.A program is able to evaluate the number of patients who have their learning at initial, basic, autonomous or strategic levels and put results indicators, for example 75% of their patients should be autonomous. The development of teaching material suitable for the target population is also crucial. The didactic triad in Andragogy and constructivism places the facilitator, the apprentice and the content on an accessible level, a fact that distinguishes it from the behavioral model.Learning is an active process where knowledge is built and modeled by experience. We have many times seen videos or manuals that aim to replace the teaching interaction of learning and avoid the creation of learning spaces based on experience, where the apprentice is the actor and not a single viewer. Step 3: Evaluation of the results of the implementation of the program.The purpose of this stage is to check the effectiveness of the program. The function is fundamentally summative. The evaluation collects results information in relation to objectives. It takes as criteria the effectiveness, defined as a degree of achievement of the proposed objectives as well as the efficiency of the results in relation to the available means and the circumstances in which the program is applied. Take as references the starting situation: the program versus itself (progress) and pre-specified levels. The Rubric presented shows us domains that patients must achieve, and the educator can teach. There are very clear indicators of the effectiveness of the programs, such as the peritonitis and exit-site infection (ESI) rates, that indicate the degree of biosecurity domain achieved by the patient. Another indicator associated with the PD technique, complications management, is evidenced by fluid overload, hypertension or annual hospitalization rates. All these rates should be related to the hours of teaching activity, its quality, method used, facilitator qualification and relevance of the developed content. Moment 4: Institutionalization of the evaluation of the program.Finally, and probably critical is the institutionalization of the evaluation of educational programs in PD. With the successive cycles of evaluation - improvement - evaluation - improvement, the full integration of the program and its evaluation is achieved, which results in the improvement of both the program and the methodology of the evaluation itself, as well as in the professional improvement of the facilitators. This point requires the integration of the entire nephrology team. For the evolution of the programs is necessary to have a critical and continuous improvement look and to share with the whole nephrology team and patients the achievements, difficulties and educational /clinical results of the y" @default.
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• W4367677534 title "Peritoneal Dialysis Education " @default.
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