role of health professionals patient education

Annals ofthe Rheumatic Diseases 1991; 50: 429-434

Role of health professionals in patient education

Jan A Maycock

Patient education is topical in the 1990s, withsome medical specialties having had longerexperience of education than the specialty ofrheumatology. Education of diabetic patients isperhaps the best example. The way in whichmembers of a multidisciplinary team are pre-pared in the skills of teaching patients shouldperhaps be questioned. Little has been publishedon the skills required for education of patientsin the United Kingdom, and what little there isseems to confuse the skill of teaching with theart of counselling.The training curriculum for medical students,

student nurses, and student physiotherapistsmakes little reference to this subject, though thenew format of nurse training-Project 2000'-places a heavy emphasis on health education.Other encouraging moves have been made inrheumatology with post basic courses in rheu-matology nursing, which have for a number ofyears included patient education skills. A newvalidated course for post basic physiotherapistsin rheumatology, organised by the Associationof Chartered Physiotherapists, Staffordshire,has also placed much stress on these skills.

Additionally, there is much evidence to indi-cate that many patients are dissatisfied with theamount and type of information given to themby health professionals. For example, the reportspublished by the health ombudsman2 criticisehealth professionals, particularly doctors andnurses, for their poor communication skills.The specialty of rheumatology in the United

Kingdom has derived its methods of educatingpatients primarily from the experience of otherspecialties and from the United States.

Care must be taken in setting up systems forpatient education to ensure that the professionalsappointed to these positions have the correcttraining and skills. Unfortunately, it has oftenbeen the case recently that nurse specialist postsare graded at staff nurse level. This means thatthe applicants are immature and do not havesufficient experience. The new clinical career

structure for nurses should mean this poorpractice of 'cheap labour' will be eradicated.

Community HealthServices,11 Orford Road,Walthamstow,London E17 9LPJ A Maycock, senior nursemanager districtnursinglquality assuranceand consultant inrheumatology nursing

Multidisciplinary teamPatient education can be a 'mine field' ofpotential problems for members of the teaminvolved in this education if the team is withoutunified direction. The Royal Commission onthe NHS3 identified the following possibledifficulties: (a) leadership of the team; (b) thenature of the corporate responsibility of theteam and its effect on the responsibility ofindividual members; (c) confidentiality and

communications; (d) legal aspects of thesematters.The report also suggested that 'the difficulties

seen in a multidisciplinary approach are moreattributable to interpersonal jealousies than toanything more solid'. These jealousies may arisefrom such issues as the challenge to the tradi-tional supremacy of doctors, the increasingassertiveness of nurses, the development of newpsychological treatments, and the creation ofnew professional roles, such as the nurse prac-titioner.An understanding of the role of all members

of the team is obviously a fundamental requisitein establishing patient education strategies, toenable members of the team to trust theprofessional expertise of the other members.Brunner and Huffington4 used experientialtechniques to show that occupational therapists,for example, felt that they were a group that wasmisunderstood and abused by other team mem-bers, who merely used them '. . . to keeppatients quiet by weaving baskets'. It is easy tofind many more examples of inappropriatereferral within a team from one professional toanother-perhaps the most common is theinappropriate referral for physiotherapy. Suchreferral is a waste of already overstretchedresources and, additionally, sends patients adouble message, completely negating the effi-cacy of the education programme, and perhapsgiving unrealistic expectations of the possibleresults of treatment.

Coordination of patient education strategiesShared care of patients with rheumatic disease isoften current practice. This obviously offers amore complete and comprehensive approach tocare but may m-ean that diverse information isgiven to them. Careful planning is needed inestablishing education programmes as all toooften these programmes are seen just as thedomain of hospital therapists. This is unrealisticas the major proportion of patients' time isspent in the community where they seek advicefrom a whole plethora of different health per-sonnel. For example, one patient may requiretreatment in the hospital outpatient departmentby a- rheumatologist, physiotherapist, nursespecialist, occupational therapist, and dietician.In the community the patient may also betreated by a general practitioner, practice nurse,district nurse, chiropodist, and pharmacist. Thelist is exhaustive with the poor patient as thecentral pivot around which all these professionalsgive a slightly different slant to the problem inhand.

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Key roles in patient educationCoordination of the multidisciplinary team,especially in hospital, has traditionally been thedomain of doctors. Consideration of theproblems which hinder and fragment the teamapproach to patient education suggests that itmay be preferable to choose another healthprofessional to sort out problems and provide alink between the community and hospital.Before considering the way in which such ahealth professional can assist the learning processfor patients the history of nurse specialistsrequires some comment.The concept of an expanding role for nurses,

which is embodied in the title 'specialist nurse',is not new. Certainly, Florence Nightingale andBedford-Fenwick in the United Kingdom, andLilian Wall in the United States reflected ascope of practice akin to that of today's 'new'practitioners. Florence Nightingale5 felt that aknowledge of nursing should concern itself with'how to put the constitution in such a state asthat it will have no disease, or that it can recoverfrom disease', and viewed this as different frommedicine. She placed great emphasis on clinicalpractice as the means of learning the art ofnursing and stated, '... . nothing but obser-vation and experience will teach us the ways tomaintain or to bring back the state of health...'. Although observation and experience didbecome a vital part of nursing, it was used toassist the doctors and to meet the needs of theinstitution rather than to develop the science ofnursing.

Influence of specialisation on the nursingprofessionThe first nurse specialists were clinical nursespecialists in psychiatry, in the United States, asearly as 1958. Also, in the United States in theearly 1960s nurse practitioners emerged, whosecontroversial role was to fill the gap in healthcare in poor rural areas where doctors could notbe recruited to work.

Nursing specialisation is slowly coming of agein the United Kingdom, and has been acclaimedby a plethora of reports and reviews; perhapsthe best known of these are the Briggs report,6the neighbourhood nursing review,7 Project2000,1 and, more recently, A Strategy ForNursing.8 It is therefore not surprising ifnurses, health professionals, and the public areconfused by the varied titles for specialistnurses, many of which tell little about the job.Thus, for example, the United KingdomCentral Council for Nursing perceives thespecialist practitioner as follows: '. . . Weenvisage a range of specialist practitioner rolesin the hospital and the community. Some ofthese will be disease linked, others will repre-sent specialist knowledge in nursing interven-tions or in health promotion. . . A number ofspecialist practitioners will develop additionalskills and become team leaders who will workwith a group of registered practitioners in aparticular area of practice. They will act asresource persons for, and managers of, theirgroups'.

The Department of Health nursing divisioncareer development project group in its report

to the NHS management board recently,recommended that a role entitled 'senior clinicalpractitioner' should be analysed and developed.This provides another conceptual frameworkaround the role and a further variation on thetitle for the public.

Care must also be taken when eliciting themeaning of the neighbourhood nursing review,7which mentions the nurse practitioner move-ment in America. Bullough has indicated thatsome American nurses practise as substitutedoctors, diagnosing and treating patients,whereas others expand and advance the role ofnursing rather than adopting a medical model.9The perplexities of the specialist role nation-

ally are reflected in the job vacancy columns,where all to often it seems that the 'left overs'are brought together under the fancy title,'specialist nurse'. There is a need, therefore, todefine clearly the term 'nurse specialist'. Perhapsthe way forward is to define the role of clinicalnurse specialist and nurse practitioner separately.

In the United Kingdom the role of clinicalnurse specialists has been developed in manyinstances medically or with emphasis on aparticular disease. Nurses, through advancedstudy and training, acquire knowledge abovethat expected of general nurses, which enablesthem to consider various alternatives whenexplaining the condition of a patient, predictingthe future course of events, and prescribingnursing actions. In this country the work ofclinical nurse specialists in diabetes nursing,psychiatry, and stoma care is perhaps the bestknown.The rheumatology nurse practitioner role in

the United Kingdom is complex and confusingas all too often this title is given to posts derivedfrom a medical need and therefore focuses onsigns, symptoms, pathology, prognosis, and thecourse of diseases. This disease orientedapproach attends to the structure and functionsof the body rather than to the total patient.

This role has been most effective when it hasdeveloped out of patients' needs. Thus, forexample, Stillwell showed that the therapeuticvalue of the service of the nurse practitioner ingeneral practice was different from but comple-mentary to that of the general practitioner.'0Burke-Masters describes another such example"among homeless and destitute men deniedaccess to proper primary care by general prac-titioners. The need of these patients was theimpetus for the development of her role as anurse practitioner within the primary medicalcare project in the East End of London.

It is important to remember that only nurseswho hold the responsibility for a completecaseload of patients are nurse practitioners inthe truest sense of the word. One or two postsexist in rheumatology but, generally, they arerare. The use of such nurses in rheumatology isgrowing nationally, however, and interestingly,many of these posts originated owing to patientneed"2-demands for information on the rheu-matic diseases were increasingly made ofalready overstretched rheumatologists bypatients attending outpatients. Only a smallnumber of nurse practitioners in rheumatologyprovide a link between hospital and community

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and coordinate an effective extended teamapproach to patient education, however.

MetrologistsMetrologists should also play a significant partin patient education as they not only have theopportunity to discuss with patients the natureof proposed treatments but can also demon-strate the efficacy of treatments with subjectiveclinical assessments. Metrologists enable patientsto feel that they are fully involved with thecourse of treatment with some say in itseffectiveness, thus returning some control to thepatients. Lack of control is often considered amajor problem by those with a chronic disease.

This role is an interesting one as it is oftencarried out by different health professionals,such as occupational therapists, physiothera-pists, and nurses. There is a division of opinionas to which group provides a more subjectiveassessment. Some think that it is difficult fornurses to be subjective as they have too great anunderstanding of pharmacology and therapeuticresponse. The metrologist and the nurse prac-titioner should work extremely closely as theyperhaps will be the health professionals who willcarry out the most intensive part of individualeducation programmes in the hospital out-patient department, general practitioner's sur-gery, and in the patients' homes.

Extended teamAs previously stated unless interprofessionaljealousies are guarded against the process ofpatient education will be severely interrupted.The team should frequently reappraise its edu-cation philosophy to allow efficient overlap ofexpertise rather than conservative protection ofrole definition. The qualities and experience ofindividual professionals should be taken intoaccount alongside the realistic time allowanceeach member can put into the programme.

This networking and interlocking betweenhealth professionals can save much confusionfor patients. For example, the patient who isbeing helped to understand the nature andcourse of his osteoarthritis and the realistictreatment options can be prescribed a simpleanalgesic by his doctor, who gives a simpleexplanation of the differences between theseand non-steroidal anti-inflammatory drugs. Thepatient then sees the nurse specialist, whoreaffirms this information, describes the disease,assesses the patient's body weight, and asks thedietician to advise on a reducing diet. The nursecan then provide support to aid compliance.The nurse can teach the patient about theimportance of keeping muscles toned and, ifnecessary, refer the patient to a physiotherapist,who will assess and determine the individualtreatment programme and carry it out. Thephysiotherapist's treatment will centre verymuch on education, and the patient can thenpass back to the care of the nurse for reinforce-ment of this treatment regimen.

Sadly, this example of good practice forpatients with osteoarthritis is not always fol-lowed for reasons which are often complex and

controversial. All too often a general prac-titioner or the media might have given thispatient unrealistic expectations of his hospitalconsultation. The patient will perhaps arrive inthe hospital outpatient department expectingthe rheumatologist to have a super new wonderdrug up his sleeve for the treatment of osteo-arthritis or may think that a course of physio-therapy will arrest the disease and removesymptoms. Published reports often state thatpatients recall most easily information theyconsider to be important. Therefore it is vital totry to change or to modify patients' initialunrealistic expectations of outcome or treatmentavailable. A treatment such as physiotherapy,for example, should not be used simply becauseit is difficult to send patients away withoutanything. Such a practice renders the educationprogramme useless and causes other teammembers considerable management problemsin the future.

Patients' problem areasThe team will have to assess each patient'sindividual educational needs holistically asmany of the patient's sociological, ethnic, andenvironmental needs must be considered toenable a suitable plan of care to be drawn up.The response to illness differs greatly between

patients. Mechanic describes illness behaviouras the patient's perceptions, feelings, andactions, which show the meaning of his symp-toms, disability, and the resulting consequenceon his daily life.'3 So it is clearly evident thatbefore embarking on any form of educationalregimen the responses of patients with rheu-matic disease to their illness need identifying.The educational strategy can then be tailored tothose areas that are actually causing anxiety tothe patients rather than to the areas that healthprofessionals identify as a priority. It is useful toconsider the list of resources which Mechanicidentifies as used by patients in adapting tostressful life demands-for example, a chronicdisabling disease such as rheumatoid arthritis.

1 Economic It is important that with therecent complex changes in social benefits,coupled with the increasing social deprivation ininner cities of disabled and elderly people, thatthe services of a skilled social worker are used.Early intervention is needed when it is requiredto enable the team to design an educationprogramme which fits the patient's lifestyle.The Arthritis and Rheumatism Council pointout that as many as 20 million people consulttheir general practitioners with some form ofarthritis'4; it is safe to say that not all these willvisit a rheumatologist. The rheumatology nursepractitioner can work closely with the generalpractitioner to coordinate this vital part ofextended team interlinkage into the community.2 Skills and abilities These should be identi-fied by the patient in partnership with the team,using the particular skills of the occupationaltherapist. If the patient is working the teamneeds to encourage the patient to try to cope foras long as possible. Where there are workproblems the occupational therapist, physio-therapist, and nurse practitioner can use these

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problems constructively to illustrate the educa-tion programme. Where there are difficultproblems the occupational therapist can liaisewith the disablement resettlement officer foradvice about job retraining, again bringing backthis information for use in the personalisededucation plan.3 Psychological defences. 'Denial' is often aword alluded to by health professionals whendescribing a patient's response to a chronicdisabling disease. The team should workextremely closely together where this is an issueas education will not be possible until anassessment has been made of how much thesedefences are part of the patient's personality andtherefore difficult to change.The patient will have difficulty in under-

standing not only his illness, drugs, and histreatment programme but must be helped tounderstand the psychological and social sideeffects of living with a chronic illness andhelped to develop the resources for coping withthem. A patient who is overwhelmed by thepyschosocial difficulties of living with chronicillness will probably absorb little of the infor-mation offered by the team.4 Personal reaction The personal reactionbetween patient and health professional mustnot be forgotten as Zeitlin'5 suggests whentalking about rheumatoid arthritis: 'the natureof rheumatoid arthritis, with its frequentlyprogressive course, forces patient and healeralike to face the task of chronic mourning. Thepyschological toll on the staff can be tre-mendous'. Therefore it should be rememberedthat there is a need for a strong bond of mutualsupport and understanding between themembers of these professional disciplines whoeducate such patients and the patients them-selves.5 Motivational impetus The patient withminimal illness behaviour is likely to have astrong motivation. Baker suggests 'that moti-vation is a difficult thing to induce whenmissing. " Some patients with intractableabsence of motivation will prove to be thosewho had never managed an adequate adjust-ment to life before the disability appeared, andfor whom the disability provides an adequateand less threatening explanation of the failure tosucceed'.Thus it can be seen that assessment of a

patient's motivation is central to the formationof a programme of education. It will also givethe team a guide as to how much change theymay be able to make in the patient's lifestylewhen trying to cope with disability.

Areas of skill which help in the design ofpatient education programmesLEARNING LEVELSTeam members must understand the types andlevels of learning they will encounter in thepatients they are treating. Learning theoristshave distinguished three types of learning: (1)Cognitive learning, which alludes to the processof thinking, of gaining information, and work-ing through it. (2) Affective learning, whichincorporates attitudes, values, beliefs, and feel-

ings which create idiosyncratic reactions. Thiskind of learning is closely tied up with apatient's motivational drive. (3) Psychomotorskill learning, which is a skill learnt by prac-tice-for example, a controlled neuromuscularmovement that the physiotherapist might teach.

Gagne'17 proposes eight categories of learning,the simplest of which is the development ofinvoluntary behaviour through classical con-ditioning. He suggests that a subject needs toprogress through each category successfullybefore achieving the next level. In other words apatient at the start of education merely recog-nises and responds to stimuli and then proceedsto more complex forms of learning, such asverbal associations, differentiation of stimuli,concept forming, and problem solving.

MOTIVATIONHealth professionals playing a part in patienteducation programmes need to understand themotivations of human behaviour. Many differ-ent theories of motivation have been proposed.A -cognitive theory of motivation has been putforward by Weiner,'8 who suggests that peopleare considered as active participants in creatingtheir own motivation through the desire to learnor in the anticipation of learning.

Application of a theory such as that of Weinerto the education of a patient with rheumaticdisease means that health professionals need toascertain that there is some degree of need tolearn and that this need requires a response suchas education to ease the tension. Anxiety is aresponse to this need and if excessive may bedetrimental to learning.

Psychologists describe two types of moti-vation: (a) intrinsic motivation, which isresponsible for behaviour patterns which con-tinue without reinforcement or reward and (b)extrinsic motivation, which persists for onlyshort periods after reinforcement stops if moti-vation has not become intrinsic. Clearly, there-fore, there is an urgent need to encouragepatients with rheumatic disease to developintrinsic motivation. Coutts and Hardy'9 clarifythe two types of motivation still further bysuggesting: 'The distinction between the twotypes of motivation helps to explain the low rateof compliance with prescribed regimens. Inhospital, reinforcement is provided by healthcare workers, the patient complies and rarelyhas the opportunity to create his own motivationby considering his health problem and itseffects. With the withdrawal of reinforcementout of hospital, the desired behaviour is likely tostop unless the patient has internalised themotivation'. Motivation should therefore beassessed early on in the treatment of a patient.

COMMUNICATIONCommunication skills are the key to goodpractice when educating patients as information,support, and advice are essential in helpingpatients adapt to new and more limited lifestylesand for many chronic illnesses communicationis virtually the only form of treatment there is.McGee20 interviewed patients in their homes

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after discharge from hospital and found that lessthan 40% complained about such things asnursing care or food, but 65% were dissatisfiedwith communication. Some studies haveemphasised the significance of the interactionbetween health professionals and patients,pointing out that character differences caninhibit successful transfer of information. Astudy by Davis2' showed that low patientcompliance was associated with the fact thatdoctors did not seek patients' participation,gave no feedback, or were formal in theircommunication with patients.Many studies have shown that there is a

strong positive correlation between satisfactionwith visits to the doctor and treatment compli-ance. Maguire22 devised an interview trainingscheme which, though designed primarily foruse by doctors, can also be interpreted for useby health professionals engaged in patient edu-cation. The principal points are: (a) give infor-mation about diagnosis and cause; (b) avoidmedical jargon; (c) explore the patient's expec-tations and if these cannot be met, explain why;(d) do not confine the interview to objectivemedical information.

Problems in communication between patientsand health professionals are usually caused bythe patient not understanding or rememberingwhat was said. This may occur because theinformation given is outside their intellectual orknowledge levels or because they have mis-conceptions which interfere with their under-standing.

Ley's23 work with general practitioner's, inwhich he taught them skills of improvingpatients' recall, is also of great use in patienteducation. His results showed that patients ofinstructed practitioners recalled a significantlygreater amount than patients of practitionerswho had not received the instruction. Hissuggestions were as follows: (a) use explicitcategorisation; (b) repeat information in differ-ent ways if possible; (c) make advice giving asspecific, detailed, and accurate as possible asopposed to making general statements.

Perhaps one of the commonest faults ofhealth professionals when communicating withpatients is their failure to realise how informa-tion they have given is open to individualinterpretation. Often this confusion takes placeafter a consultation when the patient triesto recall the verbal or written instruction.Moskowitz and Haug24 illustrate this well byciting some real experiences: (1) 'Take this drugfour times a day'. Since this means taking itevery six hours, must I wake up in the middle ofthe night? What if I forget? Should I take twowhen I remember? (2) 'Take frequent baths tohelp you relax'. Are they supposed to be hot,cold, or warm? Should I soak for a while? Isfour times a day frequent? Does it matter when?Does he think I'm too tense, that it's all in myhead? (3) 'Only use this pill if you can't standthe pain'. What does 'can't stand' mean? Howlong should I wait? Is it bad to take it? If I do,am I a weak person?Many health professionals have had experience

of this type of communication problem, whichis often picked up some time after a clinic

visit-for example, when the occupationaltherapist is treating the patient at a later date.This means that the patient has probably beenworrying over the problem and not seeing thedoctor for another few months has taken thefirst opportunity to ask another member of theteam. Much time and anguish could be saved ifthe team worked out a common approach andgave the patient a point of contact if worried-for example, the specialist nurse.

Effective communication from the teamshould be therapeutic in itself. Gazda25 suggeststhat communication is a three phase cycle:facilitation, transition, and action. Within thecycle perhaps the most important phase is thefoundation of the therapeutic relationship-thatis, the facilitation phase. The essential featuresofthis are talking, and listening in an empathetic,warm, non-directive, and non-judgmental way.Anxiety is then reduced and the patient ishelped to feel relaxed, ask questions, andrelease emotion.The challenge of identifying communication

barriers should be taken up by every member ofthe educating team. Increased skill and aware-ness by all members of the team is important.Ewles et a126 suggest a list of pointers to look outfor: (a)a social and cultural gap between educatorand client; (b) limited receptiveness of client; (c)negative attitude to the health educator; (d)limited understanding and memory; (e) insuf-ficient emphasis on education by the healthprofessional; (I) contradictory messages; and (g)overcoming language barriers.

Possibly, the quantity of information given topatients at any one time, should be added to thislist. Often, health professionals are tempted todistil knowledge and experience that they haveacquired over many years in a few minutes.Moskowitz expands this theory further bysuggesting that 'Some things can be told, somedemonstrated, some only experienced, somewritten out, some stated a single time, and somerepeated with variations. This in itself may leadto further realisation that the teaching cannot bedone all at once or by the same person'. Thisstatement confirms the importance of an ex-tended team in rheumatology, who can formu-late a coordinated approach to patient education.

CONTROLThe word control should feature strongly whenhealth professionals are developing their skillsin patient education. Many patients experienc-ing the trauma of discovering that they have arheumatic disease, with the implications ofpossible chronicity, disability, and pain, feelthat they have lost or are losing control of theirlives. It might be suggested that one of the mainobjectives in educating patients with rheumaticdisease is to give them an understanding of thedisease process, its management, and the way inwhich they can adapt their lives to the illness.Arluke27 in a study of elderly people witharthritis came to the same conclusion and sawthe concept of care as going some way towardsproviding patients with help in their struggle toregulate and keep control of their lives.

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The way forwardThe need for multidisciplinary teams to developand improve their patient education skills in thefuture is paramount in view of an aging popu-lation, coupled with the incidence of rheumaticdisease in the general population.

Patient education is rightly heralded as thera-peutic by the professionals taking part in suchprogrammes. In the light of the changes in theNHS proposed by the government's whitepaper much work will have to be done nationallyto show the efficacy of such programmes.

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2 National Health Service. Health Service commissioner, 4thReport for session 1977-1978. London: HMSO, 1977.

3 National Health Service. Commission on the National HealthService Report. (Chairman, Sir Alex Merrison.) London:HMSO, 1979.

4 Brunner H, Huffington C. Altered images. Nursing Times.1985; July: 24-7.

5 Nightingale F. Notes on nursing. Philadelphia: Lippincott,1946.

6 Briggs A. The report of the committee on nursing. London:HMSO, 1970. ((Cmnd 5115.)

7 Department of Health and Social Security. Neighbourhoodnursing: a focus for care. London: HMSO, 1986.

8 Department of Health Nursing Division. A strategy fornursing: a report of the steering committee. London: HMSO,1989.

9 Bullough B. Influences on role expansion. Am Nurs 1976;76: 1476-81.

10 Stillwell B, Greenfield S, Drury V W M, Hull F M. A nursepractitioner in general practice: working style and patternof consultations. R Coll Gen Pract 1987; 37: 154-7.

11 Burke-Masters B. The nurse practitioner surgery. SelfHealthMagazine 1988; March: 22-3.

12 Melville J. Trouble shooter in the clinic. New SocietyMagazine 1988; 13 May: 84.

13 Mechanic D. Illness behaviour, social adaptation and themanagement of illness. A comparison of educational andmedical models. J Nerv Ment Dis 1977; 165: 79-87.

14 Wood P. Arthritis and rheumatism in the eighties. London: TheArthritis and Rheumatism Council, 1986.

15 Zeitlin D. Psychological issues in the management ofrheumatoid arthritis. Psychosomatics 1977; 18: 7-14.

16 Baker G H B. Psychological management. In: Woolf D, ed.Clinics in rheumatic diseases. Philadelphia: Saunders, 1981:455-67.

17 Gagne' R M. Essentials of learning for instruction. Hinsdale,Illinois: Dryden Press, 1974.

18 Weiner B. Human motivation. New York: Holt, Rinehart andWinston, 1980.

19 Coutts L C, Hardy L K. Teaching health. London: ChurchillLivingstone, 1985: 57.

20 McGhee A. The patient's attitude to nursing care. Edinburgh:Churchill Livingstone, 1%1.

21 Davis F. Passage through crisis: polio victims and their families.Indianapolis: Bobbs-Merrill, 1963.

22 Maguire G P. Training medical students to obtain a history ofthe current problems. In: Bennet A E, ed. Communicationsin medicine. London: Oxford University Press (for theNuffield Provincial Hospitals Trust), 1976.

23 Ley P. Towards better doctor-patient communications. Con-tributions from social and experimental psychology. In:Bennet A E, ed. Communications in medicine. London:Oxford University Press, (for the Nuffield ProvincialHospitals Trust), 1976.

24 Moskowitz R W, Haug M R. Arthritis and the elderly. NewYork: Springer, 1986: 83.

25 Gazda G M, Walters R P, Childers W C. Human relationsdevelopment: a manualfor health sciences. London: Allyn andBacon, 1975.

26 Ewles L, Simnett I. Promoting health. New York: Wiley,1985: 98-102.

27 Arluke A. Judging drugs: patients' conceptions of therapeuticefficacy in the treatment of arthritis. Human Organisation1980; 39: 84-8.

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