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Asthma education: special applications for the school-age child
Nurs Clin N Am 38 (2003) 653–664
Asthma education: special applications for the school-age child Anne Meng, MN, CPNP, RNC*, Susan McConnell, MSN, BS School of Nursing, The University of Texas Medical Branch, 310 University Boulevard, Galveston, TX 77555-1029, USA
Education for partnership in asthma care is a major component of the National Heart, Lung and Blood Institute’s Guidelines for the Diagnosis and Management of Asthma [1] and of the National Institutes of Health’s Global Strategy for Asthma Management and Prevention [2]. The educational message for patients comprises basic facts including understanding the difference between asthmatic and normal lungs, understanding the use of rescue and controller medication, and avoiding triggers [1]. Because the primary feature of asthma is airway inflammation, patients must be taught the significance of airway swelling and its relationship to trigger exposure and treatment. Inflammation is an abstract concept and is difficult to teach. It is especially difficult to teach to school-age children because their thinking is characterized by concrete operations, and their self-esteem is linked to success in learning. A decade of experience teaching children self-management skills at Camp RAD, an asthma specialty camp [3], motivated the camp’s planning team to create a model to show pathophysiologic changes in the airway for schoolage children in a way that was compatible with their stage of development. The purpose of this article is to describe (1) how characteristics of the school-age child’s learning relates to asthma education, (3) how a threedimensional anatomic model of the airways can be used to teach children about changes in the asthmatic airway, (3) outcomes of teaching comparing use of the model with traditional teaching methods, and (4) implications for clinical practice.
* Corresponding author. E-mail address: [email protected] (A. Meng). 0029-6465/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0029-6465(03)00101-4
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Learning characteristics of the school-age child An understanding of theory that guides personality and cognitive skill development can provide asthma educators with a framework for appreciating the unique learning needs of children as they grow through the school-age years. According to Piaget [4], the school-age child is transitioning through a stage of cognitive development characterized by concrete operations. Distinctive qualities of the school-age child’s thinking that guide selection of teaching methods and strategies include the following: (1) thinking that is systematic and logical; (2) development of a longer attention span; (3) an ability to deal with multiple aspects of a situation or problem simultaneously; (4) development of an understanding of time, space, and rules; (5) an ability to perceive and appreciate multiple points of view; and (6) an inability to think in abstract terms. Piaget [5] also described the school-age child as an active learner facilitated by teaching strategies that embrace action and movement. Lesson plans that incorporate activities requiring school-age child learners to draw, color, write, actively move about the classroom area, and interact with each other facilitate content objectives. Lesson plans in the Camp RAD curriculum incorporate activities that require the learner to move and interact with others. The lesson on triggers engages campers in a sequential handshake game that shows the benefits of good hand washing, especially after sneezing or coughing. As the children sit in a circle, the first child dips his or her hand into a baggie filled with glitter, then turns and shakes the hand of the child sitting to the right. The handshake then proceeds around the circle from one child to the next. The children soon realize that the small pieces of glitter, representing the ‘‘germs’’ present in mouths and noses, are being passed inadvertently from one to the other. In the lesson that focuses on medications, children engage in a role-playing race, taking on the characteristics and modes of action of the different medications commonly used to treat asthma. In the concrete operations stage, experiential learning is enhanced through teaching strategies that are multisensory. School-age children are capable of and eager to accept, analyze, and understand stimuli that challenge all the senses of the body. Creative asthma education activities that incorporate use of models, manikins, graphics, metaphorical props, and video or computer enhancements can be designed to stimulate simultaneously the child learner’s senses through the experiences of touching, seeing, hearing, tasting, and smelling. Teachers must exercise caution and vigilance with multisensory approaches and use sensitivity to avoid potential overload and overstimulation of the child. As children transition through the school-age years, attention span matures along a continuum. Consideration of how well and long a child learner can focus on lesson content is crucial. When planning asthma education for this age group, educators must be vigilant in recognizing when
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the learner’s attention is waning. Grasp of foundational concepts is imperative, and lesson plans should be flexible, allowing creative and spontaneous interjection of refocusing activities. During the 20-minute lessons in the Camp RAD curriculum, counselors are trained to be continually mindful of lesson objectives, repeat them often to the children, and refocus individuals or the entire group through artful questioning and verbalization of key concepts at the conclusion of the teaching session. Erikson [6] described the personality development of the school-age child as a stage of resolving conflict between industry and inferiority. Traits influencing learning that emerge in this stage include (1) a sense of selfesteem directly linked to task completion and skill acquisition, (2) a recognition of and rising to meet the expectations of others, (3) a need to conform rather than experience the disapproval of others, and (4) a desire to be successful and have that success rewarded. Inherent in this theory is an understanding that a child who is unable to meet successfully the expectations of others may experience a damaged ego and feelings of inadequacy or inferiority. Children who emerge from the preschool years with a firm foundation of trust, autonomy, and initiative approach the school-age years with an eagerness to meet the challenges of formal education systems and rapidly changing social relationships. Dramatic changes in how the school-age child perceives the importance of information occur during personality development and have a profound impact on learning. As children enter this stage, the egocentric frame of reference that supports the dependent earlier stages transitions to a framework that recognizes the existence and importance of others and the surrounding social structures. Information that supports skill acquisition and task completion associated with this new orientation now becomes important. For the school-age child to meet the goals of this stage, he or she must embrace information recognized by significant others as useful and essential. Vygotsky’s [7] theory of cognitive development contributes to an enhanced understanding of how the school-age child learns and is useful in bridging the foundational concepts offered by Piaget and Erikson. By focusing on processes that influence development rather than the nature of the maturing child, Vygotsky rejected the notion that children learn in a linear, hierarchical manner. Instead, he described an interactive and dynamic learning process that flows back and forth as the child matures and transitions through developmental stages [8]. School-age children are concrete thinkers in an abstract world. Creative use of imagery facilitates interactive learning, which helps the school-age child begin to understand the abstract nature of much of his or her surroundings. The intellectual leap between concrete and abstract is tenuous; the fragile connections between the two must be validated for the school-age learner. In the Camp RAD lesson that explores the nature of the respiratory tract, teachers use analogy to help the children understand something that
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they cannot visualize. Capitalizing on general life knowledge, this lesson draws an analogy between a tree, a sprig of broccoli, and the respiratory tract. The teacher talks about the children’s general knowledge of trees, asking them to describe the different parts that they recognize. Then, holding the broccoli sprig upside down, the teacher explores the ‘‘trunk, ’’ ‘‘branches, ’’ and ‘‘tiny buds at the tips, ’’ helping the children draw similarities. The analogy is completed when the teacher uses an anatomic drawing of the respiratory tract, simultaneously drawing attention to the similarities between the parts of the tree, broccoli, and respiratory tract. At the conclusion of the lesson, the teacher asks the children, ‘‘Now, does this mean that your respiratory tract is really a piece of broccoli or a tree? ’’ The children laugh and shake their heads ‘‘no, ’’ validating that the intellectual leap between concrete and abstract concept has occurred. Traditional teaching tools Many children’s asthma education programs, such as Open Airways [9], Camper Health through Asthma Management Program [10], and ‘‘Yes, I Can!’’ [11], to name a few, have been developed. The teaching methodologies used by these programs are traditional (ie, hand-held diagrams, charts, and videotapes are used as supplements to didactic content). The initial teaching plan for Camp RAD included similar traditional forms of teaching aids. The foundation of the Camp RAD asthma curriculum was and continues to be a 20-minute children’s class, ‘‘What is asthma? ’’ The goal of this class is to teach children, age 7 to 12 years, how asthmatic airways differ from healthy airways and the relationship of inflammation to triggers and treatment. Two-dimensional anatomic charts of the airway were used in the early Camp RAD programs to teach basic airway anatomy. Younger children made life-sized body outlines and pasted parts of the airway onto the body outline. Plastic models showing cross-sections of the normal and inflamed airways sometimes were used with older campers. Postcamp comments from seasoned asthma camp staff indicated that despite attempts to illustrate airway changes, children failed to grasp the concept of inflammation. The teachers were frustrated with inadequate teaching models. These comments led to the design of crude anatomic models of the airway. Clear plastic from tennis ball cans was stripped of labeling, cut, and rolled into small tubes to represent sections of the airway. Gourmet-quality sponge was cut to fit as inner liners in the plastic tubes. This sponge represented the wall of the airway. In addition, some tube linings were spraypainted orange (the color of most controller medication canisters) until the paint created a waterproof seal. These tubes were used in the children’s asthma class to show swelling and the effect of controller medication. After observing the large opening in the unpainted airway tubes, the tube was immersed in water. The gourmet sponge swelled, creating a narrow airway.
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The painted tubes were placed in water and because of the water seal created by the ‘‘controller medication, ’’ these tubes remained open. Children grasped the concept of swelling with this demonstration; however, the hand-held tubes were labor intensive to make and could not be recycled after a single use. In addition, the tubes failed to show the relationship of the lungs to the body or the effect of bronchoconstriction on swollen airways. The postcamp evaluation evolved into a wish list of model capabilities. The team identified that the ideal model would show the relationship of the lungs to the body, visually contrast healthy with inflamed airways, show swelling and bronchoconstriction, simulate a wheeze, accommodate mucus, and show the link between anxiety and airway obstruction.
Three-dimensional model Design specifications called for a 3-foot, lifelike doll constructed of durable, but lightweight material for portability. Because the team was concerned about boys’ sensitivity to the use of dolls, the model was designed as a camper, with a name that originated from the camp and could be either male or female—Radical Randy. Randy’s chest opens to reveal ribs, which can be removed to reveal the surface of the lungs, trachea, and main bronchi. The right lung opens to reveal healthy bronchi, bronchioles, and air sacs. A pocket hidden in the base of the lung contains a removable bronchiole. This is a clear tube that resembles a miniature blood pressure cuff. When stored, the tube is collapsed. It is inflated slightly until patent, then is locked to prevent occlusion. A cord loosely wrapped around the tube represents smooth muscle. This cord is knotted to prevent constriction of the airway. This right airway is used to teach concepts related to the healthy airway. The left chest contains inflamed lungs. As the left lung is opened, an anxious face replaces the usual happy face of the model. The left lung opens to expose red airways that buldge around smooth muscles. A second hidden pocket contains a miniature bronchiole; however, this tube is red and has no lock. When inflated, it swells causing occlusion of the airway. A cord representing smooth muscles can be pulled taut to show bronchoconstriction. Yellow-green synthetic mucus is added to the inside of the tube as mucus. It proved technically too difficult for the manufacturer to incorporate a wheezing device in the bronchiole tube but a balloon can be used to show a wheeze. A booklet containing the children’s ‘‘What is Asthma? ’’ class in English and Spanish and a corresponding instructor guide accompany Radical Randy. Comments over the years from camp counselors indicated that a videotape of a teaching session with children would help new teachers grasp the teaching role. A children’s class was videotaped, and the tape is included in the teaching kit. The content of the children’s class is designed to teach four objectives: (1) asthma is chronic, (2) anatomy of the airway,
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(3) changes that occur in the airway during an attack, and (4) decisions to prevent flare-ups. Although Radical Randy has no direct link to the concept of asthma as a chronic condition, the camp team elected to include this objective in the children’s class because of the frequency of parents’ and children’s stated beliefs and wishes that asthma is a condition that one outgrows. If not addressed, this belief results in eventual discard of asthma medications and devices. Families then frequently are caught by surprise with a sudden, severe asthma attack and subsequent emergency department visit. Camp experience over many years proved that children have difficulty grasping the meaning of the term chronic. For developmental reasons, this objective was rephrased as ‘‘state what is meant by ’asthma never goes away.’ ’’ The concept of chronicity, however stated, is abstract and difficult for children to grasp. A principle to facilitate learning new ideas is to link the new concepts to experiences with which the child is already familiar [12]. All children are familiar with the weather. Weather is an apt metaphor because it is always present, but it is always changing, just as asthma is always present but changing. Pictures of different types of weather are shown to children and compared with asthma. A storm at night is compared with nocturnal asthma, and sunny weather is compared with controlled asthma. Clinical observation indicated that the 7-year-olds still were quite literal in their thinking. Approximately 50% of the 7-year-olds confused the metaphor with reality. This confusion was managed easily by explaining that you could have an asthma attack on a sunny day. In developmental terms, the second objective became ‘‘name the parts of the airway.’’ The parts of the airway are pointed out on Randy’s healthy right side from the nose to the air sacs. The familiar concept to children with which the airway is linked is broccoli. Use of this simile helps children remember the anatomic term bronchiole. The next objective focuses on three changes that occur in the airway during an asthma attack—mucus production, swelling, and bronchoconstriction. Links to triggers and anxiety are established at this point. The teacher explains that Randy decides to visit a friend but is unaware that the friend has a cat, a major trigger for Randy. The teacher simultaneously replaces Randy’s happy face with an anxious face. As the left chest is opened, the children note the red and buldging appearance of the airways. The left bronchiole is removed from the hidden pocket, inflated, constricted, and filled with mucus to illustrate airway changes and allow the children to see and feel limited airflow. A balloon is used to simulate the sound of a wheeze. The children are asked to identify the symptoms they experience when their asthma flare-ups. The final objective is intended to give the children a message of empowerment. The central concept is that they can make decisions to keep their lungs healthy. This message is illustrated by contrasting differences in the two sides of the lung. Use of rescue and controller medications is
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linked to relaxed smooth muscles and an open airway. The teacher explains that Randy has learned to take his controller medication every day and now revisits his friend with the cat. The children re-examine the bronchiole from the healthy side and note that it does not inflate fully, and the airway remains patent. The teacher links the open airway to use of daily controller medication.
Field tests of model effectiveness Field tests to document the effectiveness of the model were conducted in three phases over 2 years. Phases 1 and 2 examined the impact of the model on child asthma knowledge, and phase 3 examined the utility of the model in clinical practice. The questions addressed in phases 1 and 2 were as follows: (1) Does the model significantly increase school-age children’s knowledge of asthma? (2) Do school-age children prefer the model or traditional methods of learning? (3) Does the model facilitate teaching basic asthma concepts as determined by teachers? A traditional class was developed using the same objectives and content as the model class and served as the control group. The traditional class relied on charts and hand-held props, such as rubber bands and straws, to illustrate asthma concepts. Tools A 12-item, multiple-choice children’s questionnaire, based on asthma class objectives, was constructed. A team of asthma specialists reviewed the questionnaire for content validity. The reviewers included two allergy immunologists, a master’s prepared nurse educator, and a clinical specialist in respiratory therapy. Items initially were reviewed for clarity and modified according to the experts’ recommendations. Reviewers rated each item as essential, acceptable, or trivial on an importance scale and perfect, acceptable, or poor fit on a goodness-of-fit scale. Two items rated trivial or poor fit were deleted. The final questionnaire, the Children’s Asthma Knowledge Questionnaire, consisted of 10 items. A five-item children’s satisfaction questionnaire was used to rate class length, interest, fun, clarity of content, and effectiveness of model or props. Each item was rated on a 5-point Likert scale with happy or sad faces anchoring response points. A score of 5 indicated maximal satisfaction. Children’s understanding of the Likert scale was assessed by completion of a sample question relating to their response to a neutral activity, such as swimming. Teachers were asked to rate six items on the class they taught: (1) organizational flow of material, (2) clarity of material, (3) ease of use of model or props, (4) ability to engage children, (5) length, and (6) enjoyability of the class. Teachers also rated the guidebook on organization, completeness of information, ease of directions, developmental appropriateness, and
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facilitation of teaching. A 5-point Likert scale was used for the teacher evaluations. The Children’s Asthma Knowledge Questionnaire was administered before and 2 to 3 weeks after the asthma class. Child and teacher satisfaction questionnaires were completed immediately after the classes. Subjects For phase 1 testing, 60 healthy children were recruited from a public elementary school. Children were grouped in classes according to the following ages: 7 to 8, 9 to 10, and 11 to 12. There were 20 children in each age group. Children in each age group were randomly assigned, by the flip of a coin, into either the traditional or the model class, giving a total of 10 children per class. Children were excluded from the study if they had attended a previous asthma education program. Parents of children signed a consent form that was approved by the university’s institutional review board. As an incentive for participation, children received a movie coupon. Two experienced pediatric nurses were recruited and trained to teach phase 1 classes. Terminology for the 7- and 8-year-olds was simplified, and one teacher was assigned to teach one model and one traditional class to the younger children. The other teacher taught the remaining four classes—two model and two traditional classes—to the older groups of children. Phase 2 was conducted at a private elementary school. According to the same protocol as phase 1, 60 children were recruited. In phase 2, six teachers were recruited to examine the effect of different styles of teaching on children’s learning. Phase 1 results The mean score on the baseline Children’s Asthma Knowledge Questionnaire for both groups was 49%. This is a higher than expected score because subjects have a 25% chance of guessing correctly on a fouritem, multiple-choice question. It presumes previous knowledge, which could not be explained because children who were known to have received asthma education were excluded from the study. Postintervention scores for the traditional class increased 14% over baseline, and scores for the model class increased 19% over baseline. This 5% difference between groups in knowledge gained is not remarkable, but when older children (11- and 12year-olds) were examined, the differences between groups became significant. Older children taught with the model had 21% more knowledge gains than older children taught with traditional methods. Children in both groups were equally satisfied with class length (jxj = 2.4). The model group rated class as more interesting than the traditional class (jxjM = 4.4; jxjt = 3.8), but this difference was more pronounced in the older children (jxjM/older = 4.6; jxjT/older = 3.1). A similar rating was found for the variable fun (jxjM = 4.3; jxjT = 3.5;
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jxjM/older = 3.8; jxjT/older = 2.5). There was no difference between groups on clarity of class content (jxjM = 4.4; jxjT = 4.3). There was a slight difference between groups on the variable ability to understand the lungs (jxjM = 4.8; jxjT = 4.4), and this difference was wider in the older children (jxjM/older = 4.75; jxjT/older = 3.87). Phase 2 results Children in both phase 2 intervention groups showed knowledge gains postintervention, but the difference between groups, although favoring the model, showed only a small effect size (jxjM = 27%; jxjT = 21%; r = .02). Both groups were satisfied with the classes; however, the model group was more satisfied (jxjM = 4.35; jxjT = 4.05). The greatest difference in satisfaction was in the model group, which found class more interesting (jxjM = 4.5; jxjT = 3.8). An independent samples t-test showed a small effect size favoring the model. The six teachers did not differ significantly in their rating of teaching with the model class (jxj = 4.78) and model guidebook (jxj = 4.78) or with the traditional class (jxj = 4.3) and traditional guidebook (jxj = 4.77). The greatest difference in teacher ratings was for ability to engage the children with the model facilitating active engagement. This finding was supported by observational data. Children in the traditional class behaved in a traditional manner, sitting quietly unless called on. The children in the model class rose from their seats to move in close to the model. They verbally expressed amazement on seeing the lungs and expressed interest with their body language. Each class was timed, and although teaching style affected class length, traditional classes averaged 25 minutes, and model classes averaged 17 minutes. The most experienced teacher completed the model class in 13 minutes without rushing the content. Children rated satisfaction without the benefit of comparing the two educational interventions. At the final post-testing 2 to 3 weeks after the classes, children in the traditional classes had become aware that children in the model group had received education with Radical Randy. Some of these children indicated that they wished they had been assigned to the model class because they found Randy more interesting than the props they had used. No one in the model class indicated that they wished they had been assigned to the traditional class. Phase 3 field test Patient care clinics are notoriously busy, and practitioners often claim that they have no time for patient education. The phase 3 field test was designed to answer the following question: Does use of the model in busy health clinics increase children’s asthma knowledge? Comparison with traditional teaching methods was excluded from this phase.
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Several pediatricians in community-based and private practice were recruited but declined to participate due to heavy clinic workloads. Three advanced nurse practitioners were recruited to test the model in their schoolbased health clinics. Each of these schools saw an average of 900 elementary students in their clinics. To participate in the study, 59 children with asthma were recruited from the three clinics. The population of one clinic was predominately Spanish-speaking, and the classes and questionnaires were conducted in Spanish at that site. The advanced nurse practitioners were instructed on the use of the model and were told to incorporate the model into the normal working of their clinic because the purpose of this phase was to determine how Radical Randy would be used in an uncontrolled, real-life setting. Each of the three practitioners independently chose to use the model in a group class rather than for individual patient instruction. The mean baseline score on the Children’s Asthma Knowledge Questionnaire in the total clinic group was 32%. The mean postintervention score was 52%, representing a 62% increase in asthma knowledge. Although the 52% postintervention score shows that there is room for continued learning, this difference represents a massive effect size (r2 = .25). Older children tended to learn more than younger children (r = .062), but age explains only 6% of the change. Asthma severity level showed no correlation with learning. There were no differences between students who learned in English or in Spanish. Children in the clinic group indicated that the model class was the right length (jxj = 4.6), was interesting (jxj = 4.5), was fun (jxj = 4.6), and increased their understanding of asthma (jxj = 4.5). Feedback from the practitioners indicated that older children learned more and that younger children had difficulty understanding some concepts, such as controller medication. Practitioners noted, however, that many of the children with asthma were not treated with controller medication. Results from the knowledge test were consistent with this observation. One practitioner believed that it was easy to engage children and family members with the model and that it was impossible to match the visual effect of the lungs on the model with didactic teaching alone. All three practitioners stated that the interactive nature of the model helped the children understand asthma. Discussion Each of the three phases of the field tests indicated that children preferred learning with Radical Randy. Knowledge gains occurred in each of the model groups but were greatest in the clinic population. Convenience samples of healthy children were recruited for phases 1 and 2 trials. Healthy children may not have perceived a ‘‘need to know’’ the information. Children in the clinic populations had experienced asthma attacks, and according to developmental theory they would perceive the information as important. In developmental theory, this perception is crucial for learning to occur.
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Children in the model group were slightly more satisfied with the asthma education than children in the traditional group. Children were blinded to the intervention groups, however, so ratings did not compare the two methods. Only after completing the satisfaction questionnaires were the children aware that two different methods of teaching were used. Children in the traditional group sought out the investigator to request a class with Radical Randy, whereas no one in the model class requested a traditional class. If children had been exposed to both teaching methods, model satisfaction ratings may have been higher. Child satisfaction was reflected in teacher ratings that the model facilitated active engagement of the children. This active, multisensory engagement is consistent with developmental learning theory. In addition to field tests, Radical Randy has been used in asthma specialty clinics and in asthma camps. Anecdotal data from these experiences indicate that the model is essential in a group setting. The strong visual imagery of the model replaced much of the didactic content of the class and allowed the teacher to illustrate concepts in a time frame that was compatible with the children’s limited attention span. When used in a group setting, it is important to limit group size to six to eight children and to ensure that each child be given an opportunity to touch and feel the model. In the clinic setting, Radical Randy usually is used individually. Teaching is targeted toward the child, but parents also benefit as observers. Parents sometimes have requested to see the model when the practitioner attempts to explain airway changes verbally. Their feedback indicates that the model facilitates their understanding of the inflammatory process. Of greatest concern in the clinic setting is finding the time to teach. It is expected that reimbursement for asthma education will be available in the near future, particularly for practitioners who obtain certification as asthma educators. With reimbursement, there will be an increased impetus for patient education. Interactive models will help fill a teaching resource gap. Strong visual models that promote interaction can decrease teaching time significantly. Summary School-age children have learning needs unique to their psychosocial and cognitive developmental stage. Teaching that requires the learner to master abstract concepts is particularly challenging. This article describes how the idea for an interactive doll/model evolved among a group of health care professionals at a day camp for children with asthma. How this group of educators designed, developed, and field-tested the model in clinic and classroom environments are presented and discussed. Strategies related to a class on key concepts of asthma education illustrate the various ways the model can be used to facilitate learning. Field testing has shown that this
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teaching aid enhances knowledge retention and has a high degree of learner satisfaction.
References [1] National Heart, Lung and blood Institute. Guidelines for the diagnosis and management of asthma NIH publication no. 97-4051. National Asthma Education and Prevention Program’s Expert Panel Report;1997. [2] NHLBI/WHO Workshop Report. Global strategy for asthma management and prevention. NIH publication no. 02-3659. Available at: http://www.ginasthma.com. Accessed April 25, 2002. [3] Meng A, Tiernan K, Bernier MJ, Brooks E. Lessons from an evaluation of the effectiveness of an asthma day camp. Am J Mat Child Nurs 1998;23:300–6. [4] Piaget J. The theory of stages in cognitive development. New York: McGraw-Hillo; 1969. [5] Piaget J. Science of education and the psychology of the child. New York: Orion Press; 1970. [6] Erikson EH. Childhood and society. 2nd edition. New York: WW Norton; 1963. [7] Vygotsky LS. Concrete human psychology. Soc Psychol 1989;27:53–77. [8] Whitener LM, Cox KR, Maglich SA. Use of theory to guide nurses in the design of health messages for children. Adv Nurs Sci 1998;20:21–35. [9] American Lung Association. Open airways for schools program. Available at: http:// www.lungusa.org/events/astopen.html. Accessed March 4, 2003. [10] Halper A, Dudovitz B. Camper health through asthma management. NewYork, New York: American Lung Association; 1991. Distributed by Allen & Hanburys Division of Glaxo. [11] Childhood Health Concepts. ‘‘Yes, I can!’’. Atlanta, GA: Childhood Health Concepts; 1994. [12] Hoffman S. Planning for patient teaching based on learning theory. In: Smith CE, editor. Patient education: nurses in partnership with other health professionals. Philadelphia: WB Saunders; 1987. p. 159–89.
Asthma education: special applications for the school-age child Anne Meng, MN, CPNP, RNC*, Susan McConnell, MSN, BS School of Nursing, The University of Texas Medical Branch, 310 University Boulevard, Galveston, TX 77555-1029, USA
Education for partnership in asthma care is a major component of the National Heart, Lung and Blood Institute’s Guidelines for the Diagnosis and Management of Asthma [1] and of the National Institutes of Health’s Global Strategy for Asthma Management and Prevention [2]. The educational message for patients comprises basic facts including understanding the difference between asthmatic and normal lungs, understanding the use of rescue and controller medication, and avoiding triggers [1]. Because the primary feature of asthma is airway inflammation, patients must be taught the significance of airway swelling and its relationship to trigger exposure and treatment. Inflammation is an abstract concept and is difficult to teach. It is especially difficult to teach to school-age children because their thinking is characterized by concrete operations, and their self-esteem is linked to success in learning. A decade of experience teaching children self-management skills at Camp RAD, an asthma specialty camp [3], motivated the camp’s planning team to create a model to show pathophysiologic changes in the airway for schoolage children in a way that was compatible with their stage of development. The purpose of this article is to describe (1) how characteristics of the school-age child’s learning relates to asthma education, (3) how a threedimensional anatomic model of the airways can be used to teach children about changes in the asthmatic airway, (3) outcomes of teaching comparing use of the model with traditional teaching methods, and (4) implications for clinical practice.
* Corresponding author. E-mail address: [email protected] (A. Meng). 0029-6465/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0029-6465(03)00101-4
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Learning characteristics of the school-age child An understanding of theory that guides personality and cognitive skill development can provide asthma educators with a framework for appreciating the unique learning needs of children as they grow through the school-age years. According to Piaget [4], the school-age child is transitioning through a stage of cognitive development characterized by concrete operations. Distinctive qualities of the school-age child’s thinking that guide selection of teaching methods and strategies include the following: (1) thinking that is systematic and logical; (2) development of a longer attention span; (3) an ability to deal with multiple aspects of a situation or problem simultaneously; (4) development of an understanding of time, space, and rules; (5) an ability to perceive and appreciate multiple points of view; and (6) an inability to think in abstract terms. Piaget [5] also described the school-age child as an active learner facilitated by teaching strategies that embrace action and movement. Lesson plans that incorporate activities requiring school-age child learners to draw, color, write, actively move about the classroom area, and interact with each other facilitate content objectives. Lesson plans in the Camp RAD curriculum incorporate activities that require the learner to move and interact with others. The lesson on triggers engages campers in a sequential handshake game that shows the benefits of good hand washing, especially after sneezing or coughing. As the children sit in a circle, the first child dips his or her hand into a baggie filled with glitter, then turns and shakes the hand of the child sitting to the right. The handshake then proceeds around the circle from one child to the next. The children soon realize that the small pieces of glitter, representing the ‘‘germs’’ present in mouths and noses, are being passed inadvertently from one to the other. In the lesson that focuses on medications, children engage in a role-playing race, taking on the characteristics and modes of action of the different medications commonly used to treat asthma. In the concrete operations stage, experiential learning is enhanced through teaching strategies that are multisensory. School-age children are capable of and eager to accept, analyze, and understand stimuli that challenge all the senses of the body. Creative asthma education activities that incorporate use of models, manikins, graphics, metaphorical props, and video or computer enhancements can be designed to stimulate simultaneously the child learner’s senses through the experiences of touching, seeing, hearing, tasting, and smelling. Teachers must exercise caution and vigilance with multisensory approaches and use sensitivity to avoid potential overload and overstimulation of the child. As children transition through the school-age years, attention span matures along a continuum. Consideration of how well and long a child learner can focus on lesson content is crucial. When planning asthma education for this age group, educators must be vigilant in recognizing when
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the learner’s attention is waning. Grasp of foundational concepts is imperative, and lesson plans should be flexible, allowing creative and spontaneous interjection of refocusing activities. During the 20-minute lessons in the Camp RAD curriculum, counselors are trained to be continually mindful of lesson objectives, repeat them often to the children, and refocus individuals or the entire group through artful questioning and verbalization of key concepts at the conclusion of the teaching session. Erikson [6] described the personality development of the school-age child as a stage of resolving conflict between industry and inferiority. Traits influencing learning that emerge in this stage include (1) a sense of selfesteem directly linked to task completion and skill acquisition, (2) a recognition of and rising to meet the expectations of others, (3) a need to conform rather than experience the disapproval of others, and (4) a desire to be successful and have that success rewarded. Inherent in this theory is an understanding that a child who is unable to meet successfully the expectations of others may experience a damaged ego and feelings of inadequacy or inferiority. Children who emerge from the preschool years with a firm foundation of trust, autonomy, and initiative approach the school-age years with an eagerness to meet the challenges of formal education systems and rapidly changing social relationships. Dramatic changes in how the school-age child perceives the importance of information occur during personality development and have a profound impact on learning. As children enter this stage, the egocentric frame of reference that supports the dependent earlier stages transitions to a framework that recognizes the existence and importance of others and the surrounding social structures. Information that supports skill acquisition and task completion associated with this new orientation now becomes important. For the school-age child to meet the goals of this stage, he or she must embrace information recognized by significant others as useful and essential. Vygotsky’s [7] theory of cognitive development contributes to an enhanced understanding of how the school-age child learns and is useful in bridging the foundational concepts offered by Piaget and Erikson. By focusing on processes that influence development rather than the nature of the maturing child, Vygotsky rejected the notion that children learn in a linear, hierarchical manner. Instead, he described an interactive and dynamic learning process that flows back and forth as the child matures and transitions through developmental stages [8]. School-age children are concrete thinkers in an abstract world. Creative use of imagery facilitates interactive learning, which helps the school-age child begin to understand the abstract nature of much of his or her surroundings. The intellectual leap between concrete and abstract is tenuous; the fragile connections between the two must be validated for the school-age learner. In the Camp RAD lesson that explores the nature of the respiratory tract, teachers use analogy to help the children understand something that
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they cannot visualize. Capitalizing on general life knowledge, this lesson draws an analogy between a tree, a sprig of broccoli, and the respiratory tract. The teacher talks about the children’s general knowledge of trees, asking them to describe the different parts that they recognize. Then, holding the broccoli sprig upside down, the teacher explores the ‘‘trunk, ’’ ‘‘branches, ’’ and ‘‘tiny buds at the tips, ’’ helping the children draw similarities. The analogy is completed when the teacher uses an anatomic drawing of the respiratory tract, simultaneously drawing attention to the similarities between the parts of the tree, broccoli, and respiratory tract. At the conclusion of the lesson, the teacher asks the children, ‘‘Now, does this mean that your respiratory tract is really a piece of broccoli or a tree? ’’ The children laugh and shake their heads ‘‘no, ’’ validating that the intellectual leap between concrete and abstract concept has occurred. Traditional teaching tools Many children’s asthma education programs, such as Open Airways [9], Camper Health through Asthma Management Program [10], and ‘‘Yes, I Can!’’ [11], to name a few, have been developed. The teaching methodologies used by these programs are traditional (ie, hand-held diagrams, charts, and videotapes are used as supplements to didactic content). The initial teaching plan for Camp RAD included similar traditional forms of teaching aids. The foundation of the Camp RAD asthma curriculum was and continues to be a 20-minute children’s class, ‘‘What is asthma? ’’ The goal of this class is to teach children, age 7 to 12 years, how asthmatic airways differ from healthy airways and the relationship of inflammation to triggers and treatment. Two-dimensional anatomic charts of the airway were used in the early Camp RAD programs to teach basic airway anatomy. Younger children made life-sized body outlines and pasted parts of the airway onto the body outline. Plastic models showing cross-sections of the normal and inflamed airways sometimes were used with older campers. Postcamp comments from seasoned asthma camp staff indicated that despite attempts to illustrate airway changes, children failed to grasp the concept of inflammation. The teachers were frustrated with inadequate teaching models. These comments led to the design of crude anatomic models of the airway. Clear plastic from tennis ball cans was stripped of labeling, cut, and rolled into small tubes to represent sections of the airway. Gourmet-quality sponge was cut to fit as inner liners in the plastic tubes. This sponge represented the wall of the airway. In addition, some tube linings were spraypainted orange (the color of most controller medication canisters) until the paint created a waterproof seal. These tubes were used in the children’s asthma class to show swelling and the effect of controller medication. After observing the large opening in the unpainted airway tubes, the tube was immersed in water. The gourmet sponge swelled, creating a narrow airway.
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The painted tubes were placed in water and because of the water seal created by the ‘‘controller medication, ’’ these tubes remained open. Children grasped the concept of swelling with this demonstration; however, the hand-held tubes were labor intensive to make and could not be recycled after a single use. In addition, the tubes failed to show the relationship of the lungs to the body or the effect of bronchoconstriction on swollen airways. The postcamp evaluation evolved into a wish list of model capabilities. The team identified that the ideal model would show the relationship of the lungs to the body, visually contrast healthy with inflamed airways, show swelling and bronchoconstriction, simulate a wheeze, accommodate mucus, and show the link between anxiety and airway obstruction.
Three-dimensional model Design specifications called for a 3-foot, lifelike doll constructed of durable, but lightweight material for portability. Because the team was concerned about boys’ sensitivity to the use of dolls, the model was designed as a camper, with a name that originated from the camp and could be either male or female—Radical Randy. Randy’s chest opens to reveal ribs, which can be removed to reveal the surface of the lungs, trachea, and main bronchi. The right lung opens to reveal healthy bronchi, bronchioles, and air sacs. A pocket hidden in the base of the lung contains a removable bronchiole. This is a clear tube that resembles a miniature blood pressure cuff. When stored, the tube is collapsed. It is inflated slightly until patent, then is locked to prevent occlusion. A cord loosely wrapped around the tube represents smooth muscle. This cord is knotted to prevent constriction of the airway. This right airway is used to teach concepts related to the healthy airway. The left chest contains inflamed lungs. As the left lung is opened, an anxious face replaces the usual happy face of the model. The left lung opens to expose red airways that buldge around smooth muscles. A second hidden pocket contains a miniature bronchiole; however, this tube is red and has no lock. When inflated, it swells causing occlusion of the airway. A cord representing smooth muscles can be pulled taut to show bronchoconstriction. Yellow-green synthetic mucus is added to the inside of the tube as mucus. It proved technically too difficult for the manufacturer to incorporate a wheezing device in the bronchiole tube but a balloon can be used to show a wheeze. A booklet containing the children’s ‘‘What is Asthma? ’’ class in English and Spanish and a corresponding instructor guide accompany Radical Randy. Comments over the years from camp counselors indicated that a videotape of a teaching session with children would help new teachers grasp the teaching role. A children’s class was videotaped, and the tape is included in the teaching kit. The content of the children’s class is designed to teach four objectives: (1) asthma is chronic, (2) anatomy of the airway,
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(3) changes that occur in the airway during an attack, and (4) decisions to prevent flare-ups. Although Radical Randy has no direct link to the concept of asthma as a chronic condition, the camp team elected to include this objective in the children’s class because of the frequency of parents’ and children’s stated beliefs and wishes that asthma is a condition that one outgrows. If not addressed, this belief results in eventual discard of asthma medications and devices. Families then frequently are caught by surprise with a sudden, severe asthma attack and subsequent emergency department visit. Camp experience over many years proved that children have difficulty grasping the meaning of the term chronic. For developmental reasons, this objective was rephrased as ‘‘state what is meant by ’asthma never goes away.’ ’’ The concept of chronicity, however stated, is abstract and difficult for children to grasp. A principle to facilitate learning new ideas is to link the new concepts to experiences with which the child is already familiar [12]. All children are familiar with the weather. Weather is an apt metaphor because it is always present, but it is always changing, just as asthma is always present but changing. Pictures of different types of weather are shown to children and compared with asthma. A storm at night is compared with nocturnal asthma, and sunny weather is compared with controlled asthma. Clinical observation indicated that the 7-year-olds still were quite literal in their thinking. Approximately 50% of the 7-year-olds confused the metaphor with reality. This confusion was managed easily by explaining that you could have an asthma attack on a sunny day. In developmental terms, the second objective became ‘‘name the parts of the airway.’’ The parts of the airway are pointed out on Randy’s healthy right side from the nose to the air sacs. The familiar concept to children with which the airway is linked is broccoli. Use of this simile helps children remember the anatomic term bronchiole. The next objective focuses on three changes that occur in the airway during an asthma attack—mucus production, swelling, and bronchoconstriction. Links to triggers and anxiety are established at this point. The teacher explains that Randy decides to visit a friend but is unaware that the friend has a cat, a major trigger for Randy. The teacher simultaneously replaces Randy’s happy face with an anxious face. As the left chest is opened, the children note the red and buldging appearance of the airways. The left bronchiole is removed from the hidden pocket, inflated, constricted, and filled with mucus to illustrate airway changes and allow the children to see and feel limited airflow. A balloon is used to simulate the sound of a wheeze. The children are asked to identify the symptoms they experience when their asthma flare-ups. The final objective is intended to give the children a message of empowerment. The central concept is that they can make decisions to keep their lungs healthy. This message is illustrated by contrasting differences in the two sides of the lung. Use of rescue and controller medications is
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linked to relaxed smooth muscles and an open airway. The teacher explains that Randy has learned to take his controller medication every day and now revisits his friend with the cat. The children re-examine the bronchiole from the healthy side and note that it does not inflate fully, and the airway remains patent. The teacher links the open airway to use of daily controller medication.
Field tests of model effectiveness Field tests to document the effectiveness of the model were conducted in three phases over 2 years. Phases 1 and 2 examined the impact of the model on child asthma knowledge, and phase 3 examined the utility of the model in clinical practice. The questions addressed in phases 1 and 2 were as follows: (1) Does the model significantly increase school-age children’s knowledge of asthma? (2) Do school-age children prefer the model or traditional methods of learning? (3) Does the model facilitate teaching basic asthma concepts as determined by teachers? A traditional class was developed using the same objectives and content as the model class and served as the control group. The traditional class relied on charts and hand-held props, such as rubber bands and straws, to illustrate asthma concepts. Tools A 12-item, multiple-choice children’s questionnaire, based on asthma class objectives, was constructed. A team of asthma specialists reviewed the questionnaire for content validity. The reviewers included two allergy immunologists, a master’s prepared nurse educator, and a clinical specialist in respiratory therapy. Items initially were reviewed for clarity and modified according to the experts’ recommendations. Reviewers rated each item as essential, acceptable, or trivial on an importance scale and perfect, acceptable, or poor fit on a goodness-of-fit scale. Two items rated trivial or poor fit were deleted. The final questionnaire, the Children’s Asthma Knowledge Questionnaire, consisted of 10 items. A five-item children’s satisfaction questionnaire was used to rate class length, interest, fun, clarity of content, and effectiveness of model or props. Each item was rated on a 5-point Likert scale with happy or sad faces anchoring response points. A score of 5 indicated maximal satisfaction. Children’s understanding of the Likert scale was assessed by completion of a sample question relating to their response to a neutral activity, such as swimming. Teachers were asked to rate six items on the class they taught: (1) organizational flow of material, (2) clarity of material, (3) ease of use of model or props, (4) ability to engage children, (5) length, and (6) enjoyability of the class. Teachers also rated the guidebook on organization, completeness of information, ease of directions, developmental appropriateness, and
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facilitation of teaching. A 5-point Likert scale was used for the teacher evaluations. The Children’s Asthma Knowledge Questionnaire was administered before and 2 to 3 weeks after the asthma class. Child and teacher satisfaction questionnaires were completed immediately after the classes. Subjects For phase 1 testing, 60 healthy children were recruited from a public elementary school. Children were grouped in classes according to the following ages: 7 to 8, 9 to 10, and 11 to 12. There were 20 children in each age group. Children in each age group were randomly assigned, by the flip of a coin, into either the traditional or the model class, giving a total of 10 children per class. Children were excluded from the study if they had attended a previous asthma education program. Parents of children signed a consent form that was approved by the university’s institutional review board. As an incentive for participation, children received a movie coupon. Two experienced pediatric nurses were recruited and trained to teach phase 1 classes. Terminology for the 7- and 8-year-olds was simplified, and one teacher was assigned to teach one model and one traditional class to the younger children. The other teacher taught the remaining four classes—two model and two traditional classes—to the older groups of children. Phase 2 was conducted at a private elementary school. According to the same protocol as phase 1, 60 children were recruited. In phase 2, six teachers were recruited to examine the effect of different styles of teaching on children’s learning. Phase 1 results The mean score on the baseline Children’s Asthma Knowledge Questionnaire for both groups was 49%. This is a higher than expected score because subjects have a 25% chance of guessing correctly on a fouritem, multiple-choice question. It presumes previous knowledge, which could not be explained because children who were known to have received asthma education were excluded from the study. Postintervention scores for the traditional class increased 14% over baseline, and scores for the model class increased 19% over baseline. This 5% difference between groups in knowledge gained is not remarkable, but when older children (11- and 12year-olds) were examined, the differences between groups became significant. Older children taught with the model had 21% more knowledge gains than older children taught with traditional methods. Children in both groups were equally satisfied with class length (jxj = 2.4). The model group rated class as more interesting than the traditional class (jxjM = 4.4; jxjt = 3.8), but this difference was more pronounced in the older children (jxjM/older = 4.6; jxjT/older = 3.1). A similar rating was found for the variable fun (jxjM = 4.3; jxjT = 3.5;
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jxjM/older = 3.8; jxjT/older = 2.5). There was no difference between groups on clarity of class content (jxjM = 4.4; jxjT = 4.3). There was a slight difference between groups on the variable ability to understand the lungs (jxjM = 4.8; jxjT = 4.4), and this difference was wider in the older children (jxjM/older = 4.75; jxjT/older = 3.87). Phase 2 results Children in both phase 2 intervention groups showed knowledge gains postintervention, but the difference between groups, although favoring the model, showed only a small effect size (jxjM = 27%; jxjT = 21%; r = .02). Both groups were satisfied with the classes; however, the model group was more satisfied (jxjM = 4.35; jxjT = 4.05). The greatest difference in satisfaction was in the model group, which found class more interesting (jxjM = 4.5; jxjT = 3.8). An independent samples t-test showed a small effect size favoring the model. The six teachers did not differ significantly in their rating of teaching with the model class (jxj = 4.78) and model guidebook (jxj = 4.78) or with the traditional class (jxj = 4.3) and traditional guidebook (jxj = 4.77). The greatest difference in teacher ratings was for ability to engage the children with the model facilitating active engagement. This finding was supported by observational data. Children in the traditional class behaved in a traditional manner, sitting quietly unless called on. The children in the model class rose from their seats to move in close to the model. They verbally expressed amazement on seeing the lungs and expressed interest with their body language. Each class was timed, and although teaching style affected class length, traditional classes averaged 25 minutes, and model classes averaged 17 minutes. The most experienced teacher completed the model class in 13 minutes without rushing the content. Children rated satisfaction without the benefit of comparing the two educational interventions. At the final post-testing 2 to 3 weeks after the classes, children in the traditional classes had become aware that children in the model group had received education with Radical Randy. Some of these children indicated that they wished they had been assigned to the model class because they found Randy more interesting than the props they had used. No one in the model class indicated that they wished they had been assigned to the traditional class. Phase 3 field test Patient care clinics are notoriously busy, and practitioners often claim that they have no time for patient education. The phase 3 field test was designed to answer the following question: Does use of the model in busy health clinics increase children’s asthma knowledge? Comparison with traditional teaching methods was excluded from this phase.
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Several pediatricians in community-based and private practice were recruited but declined to participate due to heavy clinic workloads. Three advanced nurse practitioners were recruited to test the model in their schoolbased health clinics. Each of these schools saw an average of 900 elementary students in their clinics. To participate in the study, 59 children with asthma were recruited from the three clinics. The population of one clinic was predominately Spanish-speaking, and the classes and questionnaires were conducted in Spanish at that site. The advanced nurse practitioners were instructed on the use of the model and were told to incorporate the model into the normal working of their clinic because the purpose of this phase was to determine how Radical Randy would be used in an uncontrolled, real-life setting. Each of the three practitioners independently chose to use the model in a group class rather than for individual patient instruction. The mean baseline score on the Children’s Asthma Knowledge Questionnaire in the total clinic group was 32%. The mean postintervention score was 52%, representing a 62% increase in asthma knowledge. Although the 52% postintervention score shows that there is room for continued learning, this difference represents a massive effect size (r2 = .25). Older children tended to learn more than younger children (r = .062), but age explains only 6% of the change. Asthma severity level showed no correlation with learning. There were no differences between students who learned in English or in Spanish. Children in the clinic group indicated that the model class was the right length (jxj = 4.6), was interesting (jxj = 4.5), was fun (jxj = 4.6), and increased their understanding of asthma (jxj = 4.5). Feedback from the practitioners indicated that older children learned more and that younger children had difficulty understanding some concepts, such as controller medication. Practitioners noted, however, that many of the children with asthma were not treated with controller medication. Results from the knowledge test were consistent with this observation. One practitioner believed that it was easy to engage children and family members with the model and that it was impossible to match the visual effect of the lungs on the model with didactic teaching alone. All three practitioners stated that the interactive nature of the model helped the children understand asthma. Discussion Each of the three phases of the field tests indicated that children preferred learning with Radical Randy. Knowledge gains occurred in each of the model groups but were greatest in the clinic population. Convenience samples of healthy children were recruited for phases 1 and 2 trials. Healthy children may not have perceived a ‘‘need to know’’ the information. Children in the clinic populations had experienced asthma attacks, and according to developmental theory they would perceive the information as important. In developmental theory, this perception is crucial for learning to occur.
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Children in the model group were slightly more satisfied with the asthma education than children in the traditional group. Children were blinded to the intervention groups, however, so ratings did not compare the two methods. Only after completing the satisfaction questionnaires were the children aware that two different methods of teaching were used. Children in the traditional group sought out the investigator to request a class with Radical Randy, whereas no one in the model class requested a traditional class. If children had been exposed to both teaching methods, model satisfaction ratings may have been higher. Child satisfaction was reflected in teacher ratings that the model facilitated active engagement of the children. This active, multisensory engagement is consistent with developmental learning theory. In addition to field tests, Radical Randy has been used in asthma specialty clinics and in asthma camps. Anecdotal data from these experiences indicate that the model is essential in a group setting. The strong visual imagery of the model replaced much of the didactic content of the class and allowed the teacher to illustrate concepts in a time frame that was compatible with the children’s limited attention span. When used in a group setting, it is important to limit group size to six to eight children and to ensure that each child be given an opportunity to touch and feel the model. In the clinic setting, Radical Randy usually is used individually. Teaching is targeted toward the child, but parents also benefit as observers. Parents sometimes have requested to see the model when the practitioner attempts to explain airway changes verbally. Their feedback indicates that the model facilitates their understanding of the inflammatory process. Of greatest concern in the clinic setting is finding the time to teach. It is expected that reimbursement for asthma education will be available in the near future, particularly for practitioners who obtain certification as asthma educators. With reimbursement, there will be an increased impetus for patient education. Interactive models will help fill a teaching resource gap. Strong visual models that promote interaction can decrease teaching time significantly. Summary School-age children have learning needs unique to their psychosocial and cognitive developmental stage. Teaching that requires the learner to master abstract concepts is particularly challenging. This article describes how the idea for an interactive doll/model evolved among a group of health care professionals at a day camp for children with asthma. How this group of educators designed, developed, and field-tested the model in clinic and classroom environments are presented and discussed. Strategies related to a class on key concepts of asthma education illustrate the various ways the model can be used to facilitate learning. Field testing has shown that this
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teaching aid enhances knowledge retention and has a high degree of learner satisfaction.
References [1] National Heart, Lung and blood Institute. Guidelines for the diagnosis and management of asthma NIH publication no. 97-4051. National Asthma Education and Prevention Program’s Expert Panel Report;1997. [2] NHLBI/WHO Workshop Report. Global strategy for asthma management and prevention. NIH publication no. 02-3659. Available at: http://www.ginasthma.com. Accessed April 25, 2002. [3] Meng A, Tiernan K, Bernier MJ, Brooks E. Lessons from an evaluation of the effectiveness of an asthma day camp. Am J Mat Child Nurs 1998;23:300–6. [4] Piaget J. The theory of stages in cognitive development. New York: McGraw-Hillo; 1969. [5] Piaget J. Science of education and the psychology of the child. New York: Orion Press; 1970. [6] Erikson EH. Childhood and society. 2nd edition. New York: WW Norton; 1963. [7] Vygotsky LS. Concrete human psychology. Soc Psychol 1989;27:53–77. [8] Whitener LM, Cox KR, Maglich SA. Use of theory to guide nurses in the design of health messages for children. Adv Nurs Sci 1998;20:21–35. [9] American Lung Association. Open airways for schools program. Available at: http:// www.lungusa.org/events/astopen.html. Accessed March 4, 2003. [10] Halper A, Dudovitz B. Camper health through asthma management. NewYork, New York: American Lung Association; 1991. Distributed by Allen & Hanburys Division of Glaxo. [11] Childhood Health Concepts. ‘‘Yes, I can!’’. Atlanta, GA: Childhood Health Concepts; 1994. [12] Hoffman S. Planning for patient teaching based on learning theory. In: Smith CE, editor. Patient education: nurses in partnership with other health professionals. Philadelphia: WB Saunders; 1987. p. 159–89.