The role of self-directed learning (SDL) in managing health care: Implications for caregivers
Janet S. Valente, Ed.D.
FACS Program Development Specialist
University of Georgia Griffin Campus
Self-directed learners assume ownership for their own thoughts and actions and take control over how to respond to a given situation. The purposes of this paper are (1) to share findings from a qualitative study of older adults aged 65-89 who practice self-directed learning (SDL) as their primary approach to managing their heath and (2) to explore the potential application of SDL to the caregiver’s personal management strategies. The research data was collected through semi-structured and open-ended interviews and review of documents used by older adults in the study. Interviews of fifteen older adults were audio taped and transcribed using the constant comparative method (Strauss and Corbin 1998). Findings reveal that there are six key factors and associated themes related to understanding how older adults’ SDL is affecting their health care. These factors include motivators to take control of health, health care behaviors, contextual factors, a learning cycle of self-directed health care, individual perceptions, and management of physical and environmental. New insights into the process of SDL and healthcare were revealed, and they provided a road map of the learning cycle adults use when self-directing their health care. Caregivers who are exposed to these findings increase their knowledge and understanding of the benefits of SDL. An obvious step is that many caregivers incorporate SDL into their own lives. Caregivers becoming self-directed learners to effectively manage their own life tasks and their health care could result in sufficiently improved outcomes.
self-directed learning, self-care, older adults, healthcare, caregivers
Being a caregiver is a difficult task; it taxes one’s physical and mental strengths. Most often it requires that the caregiver learn new skills, such as safe body mechanics, daily care of a person with a disease or disability, and proper management of the home environment for the person receiving care. Even in those cases where in-home help is hired to provide some or all of the care for a family member or friend, normally the caregiver becomes the decision maker regarding hiring and scheduling of in-home services as well as quality assurance of the care provided to their loved one. Commonly, the adult caregiver is working full time, managing financial issues, household repairs, general cleaning, and providing transportation, for both their children and parents (Del Campo, Del Campo and DeLeon 2000). Frequently one sees that demands of attending to common caregivers’ tasks coupled with normal demands of everyday life leads to stress and exhaustion for caregivers. At times, many caregivers become so consumed by the demands of their caregiving activities that they often neglect to address their own needs and daily tasks. Therefore, it is important for caregivers to employ the practices of self-directed learning to assist themselves in more effectively managing their own lives as well as their caregiver role. Taking a closer look at how older adults from this study use self-directed learning to take control of their health and health care services provides insights into key factors associated with effective self-care.
We will begin our discussion by defining SDL, a concept grounded in the literature of the field of adult learning. Then we will provide a summary of the descriptive study, discuss findings, draw conclusions, and identify and reflect upon the implications that this study has for caregivers.
Self-directed learning is based on the premise that the learner assumes the primary responsibility for planning, carrying out, and evaluating learning experiences (Knowles 1975). Taking primary responsibility means that individuals assume ownership for their own thoughts and actions, and take control over how to respond to a given situation. Within the context of learning, it is the ability or willingness of individuals to direct their own learning that determines their potential for self-direction (Brockett and Hiemstra 1991). Tremblay (1981) refers to personal autonomy in learning as learning undertaken by an individual without benefit of either an institution or any other formal educational agent. Chene (1983) defines the autonomous learner as independent and able to make choices and critical judgments, while Candy (1991) characterizes autonomous learners as those who have a strong sense of personal values and beliefs. These values and beliefs provide the learner with a solid foundation for conceiving goals and plans, making and evaluating choices, accomplishing goals, and exercising self-restraint or self-discipline (Candy 1991).
Self-care in health refers to a broad range of behaviors undertaken by individuals with the intention of maintaining or promoting health (DeFriese, Konrad, Woomert, Norburn, and Bernard 1994; Ory and DeFriese 1998). The World Health Organization (1983) further defines self-care as “activities that individuals, families and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health” (p. 2). These activities are derived from knowledge and skills from a pool of both professional and lay experience (Dill and Brown 1995). The critical component of self-care practices is that they are lay-initiated and reflect a self-determined decision-making process (Royer 1995).
Description of the study
Older adults need to understand the importance of the primary factors that contribute to health maintenance. It has been noted that those adults who have taken control of their health care are typically self-directing their own learning. The purpose of the study was to further the understanding and the role of SDL by older adults as it relates to their health maintenance and management of their health care services.
The research questions that guide this study follow:
- What motivates older adults to take control of their learning regarding health care?
- What health care behaviors are controlled by self-directed learners?
- What contextual factors are controlled by self-directed learners?
- What is the process of SDL within one’s health care management?
- How does SDL affect one’s health care?
- What barriers do learners experience in the self-direction of their health care?
The epistemological frames for the study are rooted in constructionist philosophy with the intention of understanding the learning process that ultimately affects personal health. According to Crotty (1998), in the constructionist view, truth or meaning comes into existence through our engagement with our reality. “It is the view that all knowledge and all meaningful reality is contingent upon human practice, being constructed through interaction between human beings and their worlds, and developed and transmitted within their social context” (Crotty 2003, 42).
Few other issues in life require such diligence as understanding and making decisions affecting one’s personal health. When faced with illness, many individuals seek information from health care professionals, support groups, friends and family, written materials, the internet, and other sources to enhance their understanding about the management of their illness and approaches to improve their health. This study provided new understanding of how older adults interpret their experiences, construct their worlds, and make meaning of their experiences as they self-direct their learning.
Informed by the theoretical perspective of constructionism and the interpretive process, the design of this study is a basic qualitative study. Qualitative research is an inductive model of knowledge inquiry (Merriam 2002; Patton 2002), with the intent to gain greater understanding of the lived experience, in this case, of older adults self-directing their health care. A criterion-based, purposeful sampling approach was employed to identify 15 older adults for the study. These criteria included (a) being age 65 or older, (b) having had a health condition or illness for a minimum of six months, and (c) ability to offer some evidence that the subject is involved in SDL to manage his or her care.
The primary methods for data collection included the use of semi-structured and open-ended interviews and collection of documents. Interviews (typically 45-60 minutes) were audio taped and transcribed by the researcher using the constant comparative method (Strauss and Corbin 1998). Health care educational materials used by the participants were also collected. To enhance validity issues, purposeful sampling, methods triangulation, member checks, peer examinations, investigator’s position, and audit trail strategies were used to ensure consistency, dependability, and reliability of the data.
The fifteen participants ranged in age from sixty-five to eighty-nine. Eight were female, and seven were male. Seven of the females were white, and one was an African American. Three of the males were white, and four were African American. Of the eight females, four live in Georgia, and four live in Texas. The males all reside in Georgia. The educational levels ranged widely from grade four to a doctorate degree. Various professions were represented, including teacher, real estate broker, minister, military professional, nurse, accountant, mechanic, maintenance person, taxi driver, business owner, and homemaker. As for major health issues, five of the participants had high blood pressure. Three reported having heart problems. Three had experienced a major stroke; two of those three were using a wheelchair as a direct result of the stroke. Balance issues and walking posed a major health issue for two participants. Diabetes, arthritis, osteoporosis, multiple myeloma, and polymyalgia theumatica were also among the major health issues found within this group of older adults.
Based on the analysis of the research questions, six key factors and associated themes were found that related to understanding how older adults’ SDL is impacting their health care. These six key factors follow:
- Factors that motivate older adults to take control of their health by using SDL are age-related issues, other people, and the potential benefits.
- Health care behaviors controlled by self-directed learners include establishing appropriate physical activity and exercise levels, maintaining positive psychological health, and managing the specific health condition.
- Contextual factors controlled by self-directed learners are their living, public, and social environments.
- There is a learning cycle of self-directed health care.
- The effects of SDL on one’s healthcare are that it reduces threats to health, raises body awareness and sensitivity, and increases collaborative management of their health care.
- Older adults may experience barriers in self-direction of their health care due to personal physical limitations, environmental limitations, policy regulations, and personal management issues.
A closer look at these findings reveals additional insights and understanding of how these older adults are using SDL to manage their health issues. A description of each factor is discussed in more detail below.
Factor l: Motivating factors for self-directed learners
In this study, the participants recognized the connection between aging and their overall health. They understood the importance of managing their health and health care; all were involved in coping with a variety of health conditions and issues. Age-related health issues, heredity, and awareness of mortality motivated these adults to take greater control of their general health and health care by using SDL. A prime example was genetic predisposition to specific illnesses that alerts the self-directed learner to his or her increased potential for specific diseases. This awareness motivated the learner toward conducting SDL activities that resulted in incorporating behaviors that help maintain good health. In general, an understanding of the relationship between health and mortality serves to stimulate and accelerate SDL.
Older adults are were also motivated to take control of their health care through SDL by contact with others, such as health care providers, family, and friends, and their belief in a higher power. The perceived and real benefits resulting from SDL served to further motivate the participants toward achieving personal health goals such as weight control, exercising, regaining strength, and blood pressure management. Participants recognized that the correlation between one’s health and one’s independence is perhaps one of the most important factors driving proactive involvement in the self-direction of one’s health care.
Overwhelmingly, the older adults in this study possess a positive outlook about their health and their health care. One participant, Randy, believes that managing his health and his health care is “making a plan to live.” He explains, “This plan for living should incorporate realistic preventative measures of health management suited to the individual’s needs.”
Factor 2: Health behaviors controlled
These findings reveal that management of health conditions using SDL requires a variety of procedures and activities that are incorporated into the daily lives of these older adults, such as controlling diet, monitoring conditions, managing medications, and using assistive devices. The self-directed older learner typically establishes lifestyle behaviors that target and manage a specific health condition based on the individual’s level of physical and psychological strength. Commonly, these activities are enhanced by a positive outlook on life which, in turn, facilitates better health and well-being.
Factor 3: Contextual factors controlled by the self-directed learner
The contextual factors controlled by older adults’ SDL include both their personal living environment and their public/social environments. Participants in this study choose to live in accessible homes that meet their current and immediate future needs. They typically associate with positive people. Group functions held at churches, clubs, or senior centers contribute to their well-being by providing greater opportunities for social interaction, health education, spiritual inspiration, and volunteerism.
Factor 4: The learning process in self-directed health care
Figure 1 shows the self-directed learner’s health care process cycle. The SDL process involves negotiation and socialization as older adults manage their health care. Often this process is triggered by a health event, which acts as an impetus to start and move individuals through the cycle of learning. Thus, the learner then moves forward, as illustrated by the arrow pointing to the right, to contact a health professional seeking confirmation and diagnosis of the health condition. This learning cycle is learner initiated; typically, this occurs immediately after the individual receives a diagnosis. From this point, the learner moves to acquiring and assessing information, choosing treatment(s), monitoring and reflecting on the result of treatment interventions, and managing adjustments in his or her lifestyle and treatment(s). The arrow between the health care professional and the cycle of learning is two-sided, pointing in both directions. This reflects that during the process of learning, the learner moves forward into the cycle of learning and then typically moves back to collaborate with a health care professional for additional information or for a better understanding of information gathered. This process and cycle of learning occurs continuously during recovery from an accident or illness, as chronic conditions are managed, and other health events emerge.
Figure 1: Health care process model. A flow chart representing the decision and management responses to a health care event.
Factor 5: Perceptions of the effect of SDL on older adults’ health care
Older adults participating in this study perceive that they reduce threats to their health by being actively involved in SDL regarding their health and health care services. What these older adults actively involved in SDL learn helps them take charge and control their specific health issues with a greater sense of awareness and sensitivity about their health and their health care services. They often choose to examine a variety of educational resources to determine, evaluate, and understand treatment options. This gathering of information enhances the self-directed learner’s understanding of his or her health care issues and facilitates and enhances collaborative working relationships with health care professionals in the development of treatment plans that work best for the individual SDL.
Factor 6: Barriers to learners’ experience in the self-direction of health care
Learners do experience some challenges associated with self-directing their health care. Physical limitations such as difficulty walking, changes in balance, weakness and exhaustion, and vision problems coupled with the normal changes associated with aging can easily become barriers to self-directing one’s health care activities. Environmental issues such as increased difficulty in navigating outings (especially in inclement weather conditions), new learning environments, meeting new people, and current living environment may create challenges to self-directing one’s health. Additionally, changes in medical care regulations and policies can limit services, challenge one’s attempts to manage one’s health, or both. Finally, personal management issues such as procrastination, frustration, laziness, and managing depression, anxiety, and fear can become barriers to self-direction of one’s health.
Overall study conclusions
Three conclusions regarding how older adults use SDL to affect their health care can be drawn from this study:
- Older learners in this study took control of certain aspects of their health care.
- The SDL process specific to health care involves acquiring, assessing, choosing, and adjusting/managing on a continuing basis.
- Self-directed behaviors are perceived by self-directed learners as positively affecting health care.
Furthermore, this study provides new insight into the behaviors and lifestyles of older adults involved in self-directing their health care. The positive attitude and enthusiasm for life reflected throughout the study’s interviews provided a remarkable illustration of the strength and fortitude that older adults engaged in SDL maintain regardless of the number and severity of the health issues they are managing. The stories provided by these self-directed learners offer insight into a new and hopeful relationship between health, learning, and the resulting quality of life.
The results of this study provide practice implications for caregivers, gerontologists, social service workers, health-, housing-, and adult educators as they provide learning opportunities for older adults that encourage them to take control of their behaviors and their lives. According to the American Society of Aging, health promotion for older adults doesn’t just mean teaching elders about healthy behaviors, it means motivating them to change (2012). An individual’s desire to begin practicing healthy living is often triggered by a wide range of other motivators such as a change in health, illness, accident, friends and family, mentors, beliefs, culture, and environment. Because self-directed learners typically respond to these motivators, it is important to provide educational programs targeting older adults connected to these events and, typically, social events involving older adults. Furthermore, as educators, we must realign our view of older adults from patients to self-healers (American Society of Aging, 2012). Self-healing connotes that these adults are becoming self-directed in their approaches to management and control of their health. However, there is the potential for learners to get incorrect or invalid information or to misinterpret information that may result in negative health outcomes. Therefore, as adult educators or caregivers it is important to recognize this potential for harm and to counter unintended results by strongly emphasizing the importance of ongoing consultations between health care professionals and older adults participating in managing their health and health care services.
The emphasis currently being placed on self-responsibility for one’s health by the medical establishment reinforces the importance of the role that educators and caregivers can play by providing educational opportunities that empower seniors to become SDL. Typically, there is a knowledge gap between medical specialists and patients. The adult educator and caregiver can assume a key role in closing this information gap by working collaboratively with health professionals in designing appropriate and culturally sensitive training events and materials. Further, adult educators and caregivers can perform a needed service by being the channels through which this needed information is provided to target populations. Dissemination of criteria health care information can be coupled with increasing the awareness of older adults and caregivers regarding the potential health benefits easily obtained by incorporating SDL into their lifestyles.
Although the initial study was not designed to gather data on caregivers, it appears that caregivers who use the process of SDL would be better equipped to maintain their own health, lifestyles, and manage their caregiving tasks. Through SDL, an individual gains a “sense of control” over their life situations. By reviewing the specific factors that motivate learners to take charge of their health, we find the essential keys to maintaining good health and wellness such as controlling diet, monitoring conditions, and being physically active. Furthermore, as noted in the study’s findings, SDL does not occur in isolation; there is a reliance on friends and family, community, and health care professionals. Friends played a key role in helping adults facilitate the SDL process by confirming and supporting choices that were made by the learner. These interactions and connections with other people are known to protect and improve emotional health (Cacioppo, Hawkley, Crawford, Ernst, Burleson, Kowalewski, Malarkey, Cauter, and Berntson 2002), which is so important to the health of the caregiver.
By review of the findings on the learning process, we learned about the key elements in the processes used by self-directed learners as they manage their health care. This process begins with a health event and evolves from the health care professionals to a self-directed learning process which incorporates acquiring and assessing information, making choices, monitoring and reflecting on treatment results, and managing adjustments in lifestyle, treatment, or both. With a better understanding of this process of SDL, a caregiver is given tools/options that can be used to not only manage his or her own health care but also care of others.
It also must be recognized that there may be barriers associated with taking control of health. Some of the most-mentioned barriers in this study were those related to personal physical limitations, weakness, and exhaustion. We also learned that one’s perception of the effect of SDL on one’s health care plays a role in making a decision to become actively involved in the process. However, those who do take charge and control their specific health issues have a greater sense of awareness and sensitivity about their health and health care services. Consequently, the adoption and practice of SDL may hold promise to promote increased awareness and a sense of control over one’s health for caregivers.
In addition, caregivers often are in charge of managing the health care services for the individual for whom they provide care. Caregivers typically communicate with a large variety of health care providers. Commonly, older adults are managing chronic conditions where they may see seven different physicians and fill at least 20 prescriptions per year (Anderson and Horvath 2002). Historically, health care providers spend little time providing instruction and communicating with these older adults and their caregivers. This trend will increase as both the population of older adults needing ongoing medical care increases and health care needs of individuals, within this group, increases.
It is therefore of critical importance that caregivers use a self-directed approach in working with health care providers to promote increased awareness of health and health care issues, treatment requirements, and lifestyles that promote good health. Increased participation in SDL by older adults can reduce the burden of care on caregivers. By incorporating SDL into their own lives, caregivers should be able to better manage the daily demands of being a caregiver thus reducing the stressfulness of the caregiver role. Maintaining the emotional health and well-being of caregivers is a critical contribution to the overall successful management of caretaking duties.
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