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approbation of algorithm of educational speech interaction of the doctor and the patient

The developed algorithm of educational speech interaction of the doctor and the patient, directed on formation of representations about
zdorovesoobraznom behaviour at patients with chronic illness of kidneys of V stage receiving treatment by a hemodialysis, has demanded practical approbation which was spent since September 2011 till December, 2017.

In research «chronic illness of kidneys of V stage», and receiving replaceable nephritic therapy by a hemodialysis 123 patients having the diagnosis have taken part in clinics of of St.-Petersburg (clinic PsPbGmU of I.P.Pavlova, 15 city hospital). The patients who were taking part in research, were at initial stages of treatment by a hemodialysis. Middle age of patients made 55,01±13,83 (min 19, max 77). Among the investigated patients there were 57 women (46 %), 66 men (54 %). All patients were kognitivno sohranny and had no serious mental diseases.

Patients have been divided into experimental and control groups. With patients from experimental group the educational conversation by means of the developed pedagogical educational text was spent. With patients from control group standard interaction, characteristic for the initial stages of treatment was carried out by a hemodialysis. The experimental group consisted of 63 patients, (34 men, 29 women), middle age - 54,17±13,78. The control group included 60 patients, (32 men, 28 women), middle age 55,9±13,94.

Educational pedagogical work with patients from experimental group was carried out as follows. The doctor led the discussion, concerning features of conducting zdorovesoobraznogo a way of life in the conditions of chronic replaceable therapy by a hemodialysis. In the course of conversation the doctor addressed to patients the developed pedagogical educational text including a complex of educational speech messages. These messages also were produblirovany in writing and were offered patients as a distributing material.

Interaction with patients was carried out on the basis of joint model of the profession of a physician assuming partnership and parity relations which admit the extremely significant at work with the patients receiving treatment by a hemodialysis as efficiency of therapy at the given kind of treatment is caused by cooperation of the doctor and the patient.

Within the limits of joint model the doctor and the patient are considered as some kind of partners which in common struggle with disease which is available for the patient. Preservation of health of the patient becomes an overall objective of their interaction. This model assumes full informing of the patient on a condition of its health, the diagnosis, the treatment forecast, ways with which help it is possible to cope with illness and to keep health [128]. Thus there are also certain complexities in application of joint model: not each patient is ready to perception of the difficult information of medical character, and not each doctor can state it in the form accessible to the patient. Distinctions in kulturnoyoobrazovatelnom level, a way of life of the doctor and the patient also frequently conduct to impossibility to reach mutual understanding between these two subjects of treatment. Complexities can arise and because the joint model should come in the stead of working models, that is supersede other models of interaction of the doctor and the patient, taken roots in medical practice [128].

Nevertheless, introduction of joint model is considered the most defensible in work with patients, especially with the patients having long, chronic diseases. The Mediko-psychological researches spent at the Moscow mediko-stomatologic university of A.I.Evdokimova [8, 242] prove efficiency of use of the given model as it is connected with increase at the patient of subjective satisfaction treatment. In conformity with these positions, the educational speech developed for patients
Messages have been formulated with a support on the basic characteristics peculiar to joint model of interaction of the doctor and the patient.

Also features of patients have been taken into consideration. In the course of preparation for pedagogical educational conversation the doctor received data on features of each concrete patient from the case record where these data were brought by the clinical psychologist who, according to the treatment standard, is in each branch of a hemodialysis. In funktsional such expert, connected, first of all, with hit on a hemodialysis and the further adaptation or possible dezadaptatsiej gathering of the information on the patient enters into treatment situations. Thus, on the basis of the received data the doctor had a possibility to individualise process of pedagogical interaction.

For the purpose of more detailed adaptation of the text of educational conversation the information on following psychological features of patients has been used: uneasiness levels, ekstraversija and an introversion, ways sovladajushchego behaviour and level of the subjective control. Research of these features was carried out by means of following techniques:

1. The scale of alarm C.D.Spilbergera adapted by JU.L.Khanin (a scale of alarm Spilbergera-Hanina) - a technique, allowing to define situational uneasiness (emotional reaction to a certain situation) and personal uneasiness (reflecting property of the person to perceive the big range of situations as potentially dangerous, and definitely to react to it) [79, 302]. Level of situational uneasiness at patients on the average составлял40,79± 7,8 (min = 21, max=63), level of personal uneasiness - 43,03± 7,33, min=27, max = 59).

2. The repertoire of strategy sovladajushchego behaviour was studied by means of a questionnaire of ways sovladajushchego behaviour Lazarusa [104]. Most actively patients used such strategy sovladajushchego behaviour, as Planning of the decision of a problem, Self-checking, Search of social support and responsibility Acceptance. Positive
Revaluation and distantsirovanie were applied hardly less actively. Such kinds of strategy sovladajushchego behaviour as confrontational koping and flight-avoiding, were applied less often in comparison with other strategy. As a whole, patients showed wide enough repertoire of koping-strategy. Average values on strategy sovladajushchego behaviour are presented in the table № 1.

Table 1

The koping-strategy used by patients (average values)

The koping-strategy used by patients
«Planning of the decision of a problem» 71,54±16,98
"Self-checking" 69,39±16,38
«Responsibility acceptance» 66,36±17,44
«Search of social support» 64,38±20,51
«Positive revaluation» 57,75±19,02
"Distantsirovanie" 52,51±19,55
«Confrontational koping» 47,62±19,25
"Flight-avoiding" 44,55±18,41

3. The analysis of level of an ekstraversii-introversion was carried out by means of personal questionnaire Ajzenka (EPI) [122]. In the investigated group of 14,2 % of patients (9 persons) characterised high levels ekstraversii and low levels nejrotizma (these patients could be carried to type of sanguine persons). 17,4 percent (11 persons) had low levels ekstraversii and low levels nejrotizma (and could be carried to type of phlegmatic persons). 39,6 % (25 persons) had a combination of high level nejrotizma with low level ekstraversii (they could be carried to type of melancholiacs). 26,9 % the person (17 persons) had a combination of high level ekstraversii and high level nejrotizma (choleric persons). One person (1,5 %) showed "intermediate level" between ekstraversiej and an introversion at high level nejrotizma (the choleric person - the melancholiac).

Similar results (prevalence of high level nejrotizma among the investigated patients), probably, have been caused by that stressful situation in which there were patients by the moment of the beginning of pedagogical work with them (presence of a heavy somatic condition and stress from comprehension of necessity of lifelong treatment by a hemodialysis).

4. For an estimation of level of the subjective control in various spheres of a life of the patient, including in the field of health, the technique «Level of the subjective control», based on the concept of a locus of the control of J has been used. Rottera, and the adapted E.F.Bazhinym, E.A.Golynkinoj, L.M.Etkindom. The format of answers using a 6-ball scale with gradation from the full consent (+3) before full disagreement (-3 [13] has been used. Results of research of level of the subjective control are presented in the table № 2.

Table 2

Average values of a locus of the control of patients

Values by technique USK
Io (the general internalnost) 4,07±1,29
Id (in the field of achievements) 5,33±1,64
In (in the field of failures) 4,68±1,5
Is (in the field of family relations) 5,26±1,72
Ip (in the field of relations of production) 4,22±1,37
It (in the field of interpersonal relations) 5,46±1,7
From (in the field of health) 4,14±1,85

Thus, it is possible to draw a conclusion that for patients moderate levels of personal and situational uneasiness were characteristic, wide enough repertoire of koping-strategy and the locus of the control approached to norm. Also patients had high levels nejrotizma more often; in the investigated group introverts numerically prevailed. However in the investigated group of patients the picture was
The non-uniform: there were also patients high enough levels of situational and personal uneasiness, and with low levels; the patients showing high levels of intensity of various kinds kopinga, patients both with eksternalnym, and with internalnym level of the subjective control. Thus, at planning and realisation of pedagogical educational conversation by each concrete doctor the personal profile of the patient with which it planned was taken into consideration and then realised educational work.

As a whole, experimental approbation of the developed educational pedagogical text included following stages. At carrying out of the pedagogical educational conversation devoted to rules of conducting zdorovesoobraznogo of a way of life in the conditions of treatment by a hemodialysis, the doctor should take up the various questions connected with changes in all areas of a life of the patient. Thus, the doctor as the teacher, has been obliged to inform to the patient the universal block of the information, concerning all spheres of ability to live of the patient, mentioned by disease (first of all, a mode of visiting of procedures, a diet, a drug intake). The text of such conversation included a complex of the universal statements concerning smyslozhiznennyh of aspects

zdorovesoobraznogo behaviour; it also included prognostichesky the block (taking up questions of the forecast of a life and health in case of observance and non-observance zdorovesoobraznogo a way of life) and actually biomedical block (including the information concerning how it is necessary itself for a message in the conditions of treatment). The used joint model of interaction of the doctor with the patient assumed detailed, on the basis of language, clear to the patient, an explanation of each position, its concerning expedient within the limits of treatment by a behaviour hemodialysis (including food, pharmacological, disciplinary). Any recommendation of the doctor has been built as carefully proved. For example:

1. You also cannot use the food rich with phosphorus (dairy products, cheese, eggs, groats). Consumption of such food leads giperfosfatemii (to accumulation neogranicheskih phosphorus connections in blood), and it involves infringement exchange calcium-phosphoric that becomes the reason of development of a tumour of parathyroid glands, damages of bones, accumulation of connections of calcium and phosphorus in serdechnoyososudistoj to system and increases in risk of a heart attack and a stroke.

2. In day you can use the squirrel nearby І, 2 grammes on kg of weight of a body. Such quantity of fiber is necessary for your organism as during a hemodialysis many amino acids with which it is necessary to fill can be lost. At the same time, superfluous consumption of fiber leads to formation of a considerable quantity of nitrogenous slag, that in addition loads all systems of an organism. [2]

Following the results of the given talks the doctor made an estimation of level of mastering of the knowledge received by the patient. Studying of level of representations about conducting regulations zdorovesoobraznogo a way of life, generated after carrying out of pedagogical educational conversation, was realised by means of specially developed questionnaire (the Appendix 2). By means of a questionnaire the doctor could check understanding the patient of all important parties of necessary behaviour which have been put in pawn in a context of educational conversation.

Questionnaire application has allowed to reveal level sformirovannosti representations about smyslozhiznennyh aspects of preservation of health, understanding of the forecast of the further life and a state of health in case of conducting zdorovesoobraznogo a way of life and in case of its infringement, and also, actually biomedical aspects of behaviour on a dialysis (how much regularly it is necessary to visit procedures how
To eat etc.). With that end in view corresponding questions have been presented respondents.

Following the results of the analysis of results of a questionnaire following results have been received.

1. Ninety eight percent of patients of experimental group (62 persons) have characterised therapy by a hemodialysis as treatment which is capable to keep their life and health within long years. In control group have in a similar way characterised treatment also 98,3 % of patients (59 persons). In each of groups there was one patient, answered "do not know", that is possible, has been connected with the alarm which has arisen concerning a kind new to it of therapy.

2. Health of the patient as a responsibility zone as doctor, and the patient 95,2 % of patients of experimental group (60 persons) and 73,3 % of the patient control (have characterised 44 persons) groups.

3. A right answer on the third question, on necessity to accept

The recommended preparations and to reconstruct the schedule of the life according to recommendations of the doctor of a distance of 98,4 % (62 patients)

Experimental group and 90 % (54 persons) control group.

4. The fact of that a hemodialysis is a compulsory procedure, 96,8 % of patients of experimental group (61 persons) and 93,3 % of patients of control group (59 persons) have been acquired.

5,6. Correct representations about a fistula, have been generated at 96,8 % of patients of experimental group (61 persons) and 98,3 % of control group (59 persons), about necessity of its change - at 92 % of patients of experimental group (58 persons) and 88,3 % of patients (53 persons) control group.

7. Adequate representations about duration of a session of a dialysis have been generated at 96,8 % of experimental group (61 persons) and 81,6 % control (49 persons).

8. How it is necessary to behave during hemodialysis procedure, correct representations имели100 % of experimental group (63 patients) and 96,6 % control (58 patients).

9. The understanding of the reasons of weighing before a session of a dialysis and after a session was correct at 100 % of patients of experimental group (63 persons) and 81,6 % of control group (49 persons).

10. Understanding of that, than admissions of sessions of a hemodialysis are dangerous took place at 98,4 % of patients of experimental group (62 persons) and 85 % of control group (51 persons).

11. Correct representations about the substances which are a part of a foodstuff which can harm to health, have been generated at 100 % of patients of experimental group (63 persons) and 87,3 % of patients of control group (55 persons).

12-13. Knowledge of the products leading giperkaliemii were correct at 100 % of patients of experimental group and 96,6 % of control group (58 persons), about the products leading giperfosfatemii were correct at 100 % of experimental group (63 patients) and 96,6 % of patients (58 persons) control group.

1 4. Representations about norms of consumption of fiber were adequate at 96,8 % of experimental group (61 patient) and 80 % of patients of control group (12 persons).

15. Representations about correct consumption of sodium it has been generated at 98,4 % (62 patients) experimental group and 88,3 % of control group (53 patients).

16. Hundred percent of patients (63 persons) from experimental group could answer correctly, in what consequences results consumption of salt by the person receiving treatment by a hemodialysis. In control group a right answer of a distance of 86,6 % of patients (52 persons).

17. The majority of patients both experimental, and control groups, have described otvarivanie and suppression as the best way of cooking (100 % and 90 % accordingly).

18. 100 % of experimental group (63 patients) knew about a correct diet and 76,6 % of patients (46 persons) control group.

19-20. Correct knowledge of consumption of necessary quantity of a liquid were available for 100 % (63 patients) experimental group and 83,3 % of patients control groups (50 persons), about consequences of infringement of a vodno-drinking mode - у100 % of patients of experimental group (63 persons) and 88,3 % of control group (53 persons).

21. On necessity of accompanying medicamentous therapy have informed 98,4 % of experimental group (62 persons) and 83,3 % control groups (50 persons).

22. Correct representations about the factors providing good state of health of the person, being on treatment by a hemodialysis, have been generated at 98,4 % of experimental group and 83,3 % of patients of control group (50 persons).

The small variability of data in experimental and control group testifies that at patients of control group and at the moment of research adequate enough representations about conducting regulations zdorovesoobraznogo a way of life have been generated. At the same time it is important to take into consideration, what even some erroneous representations or forgetfulness of the patient can play a fatal role for health and even a life of the patient. So, as a whole komplaentyj the patient can use in food a significant amount of tomatoes or a melon and to die of cardiac arrest owing to giperkaliemii. For this reason it is important to aspire to bring to naught all possible wrong knowledge of treatment and a behaviour mode on a hemodialysis. The and correct knowledge of the patient will be more exact, the it is more probability of preservation of its health and life. On the diagramme №1
Levels sformirovannosti representations about conducting regulations zdorovesoobraznogo a way of life on a hemodialysis at patients of experimental and control group are presented.

The diagramme 1

Answers of the patients receiving treatment by a hemodialysis, from experimental and control groups on questions,

Containing in a questionnaire

On the diagramme 2 data about quantity of the patients breaking the doctor's instructions in experimental and control groups are presented.

The diagramme 2


The analysis of efficiency of pedagogical educational conversation would be incomplete if the estimation of behaviour of patients after carrying out with them pedagogical educational conversation has not been made. During a control stage of experiment supervision over behaviour and a condition of patients of experimental and control groups in dynamics (within one year) was carried out. Supervision was carried out by attending physicians and brought in the case record of each patient. The analysis of data from the case record has allowed to reveal, how much patients have acquired the knowledge received in the course of educational work, began to observe zdorovesoobraznyj a way of life and as it was reflected in their somatic condition.

According to the researches devoted komlaentnosti of patients receiving treatment by a hemodialysis, (that is degrees of their adherence zdorovesoobraznomu to behaviour) exists three most widespread criteria of infringement komplaensa: admissions of sessions of a dialysis more often, than once a month, or regular reduction of duration of procedure more than for 10 minutes; the big increases in weight which are fixed in an interval between procedures (as consequence of infringement of a diet and a vodno-drinking mode); increase of level of phosphorus in blood by results of analyses (as consequence of infringement of a mode of reception fosforosvjazyvajushchih preparations) [39]. Thus, the analysis of behaviour of patients within a year was carried out in following directions:

1. A regularity of visiting of procedure of a hemodialysis. According to standards of treatment the patient should visit procedure of a hemodialysis a minimum 3 times a week (depending on features of a somatic condition of each patient probably bolshee quantity of visitings in a week). Duration of each procedure makes 4-5 hours (depending on the recommendations of the doctor caused by a somatic condition of each concrete patient).

2. Results of analyses of blood on which it is possible to judge a correct mode of reception of medicines. Maintenances of phosphorus not deviating on level from recommended norm indicators testified to observance of a mode of reception fosforosvjazyvajushchih medicines.

3. Results of measurement of weight at each patient before hemodialysis procedure. Absence strong (excessive) mezhdializnyh increases in weight testified to observance of a diet and a vodno-drinking mode.

All cases of infringement of a mode of treatment and doctor's instructions were fixed in case records of patients. Following the results of the analysis of case records of patients in which features of behaviour of patients have been reflected, on the basis of the specified criteria within a year the following has been revealed. In control group the ordered mode of treatment was broken by 23 patients (38,3) - 10 women and 13 men. The most active infringements have been revealed in sphere of a food and observance of a vodno-salt mode of 31,6 % (19 persons). Admissions of sessions of treatment and attempt to reduce them, and also admissions of medicines - 3,3 % (2 persons) were less active.

In the experimental group which was trained by means of educational speech messages, 4 patients (all 4 - men), breaking the ordered medical mode (6,3 %) patients have been revealed. Two patients broke a diet, one patient - passed treatment sessions, one more tried to pass them, however, consulted before it to the doctor who forbade similar admissions.

Regular visitings of a hemodialysis by the majority of patients and observance of other medical recommendations by the majority of patients of experimental group (93,7 %) have allowed to verify that fact, that at bolshej parts of patients following the results of pedagogical educational conversation have appeared steady representations about smyslozhiznennyh aspects of preservation of health, about the importance of visiting of procedures, treatment regulations, and possible consequences of infringements of doctor's instructions. That is,
Patients have acquired those aspects of conducting zdorovesoobraznogo a way of life which the doctor informed within the limits of educational conversation. Observance of necessary instructions (a mode of visiting of a dialysis, a diet and reception of medicines) has allowed to verify that position, that the person has realised conducting regulations zdorovesoobraznogo behaviour.

For the purpose of acknowledgement of a hypothesis of research, statistical processing of the data received during experiment about interrelation of level of knowledge about zdorovesoobraznom behaviour on a hemodialysis, behaviour and state of health of patients of experimental and control groups has been spent. The following procedure of processing (coding) of data has preliminary been spent.

Level of understanding of principles of conducting zdorovesoobraznogo a way of life on a hemodialysis was estimated by means of a questionnaire. Results on a questionnaire have been presented in the form of points (from 0 to 22).

Features of behaviour of patients were considered as follows. In case of infringement komplaensa to the patient 0 points, in a case komplaentnogo zdorovesoobraznogo behaviour - 1 point were appropriated.

The generalised data about state of health of patients were fixed similarly. In case of the expressed infringements of functioning of the organism, revealed by results of analyses, to the patient 0 points, in case of their absence and enough the compensated somatic condition of the patient - 1 point were appropriated.

Then statistical processing of these data for the purpose of interrelation revealing between the specified parametres was spent. In this connection, following procedures have been carried out.

1. For the purpose of interrelation revealing between level of understanding of principles of behaviour of patients on a hemodialysis and, actually, komplaentnym zdorovesoobraznym behaviour, patients both in control, and in experimental group have been divided into subgroups on the basis komplaentnosti. At comparison by means of criterion the God-send-uitni
Results of subgroups on a questionnaire (komplaentnoj and nekomplaentnoj subgroups) both in experimental, and in control group, have been revealed statistically significant distinctions in the field of understanding of principles zdorovesoobraznogo behaviour (on points in a questionnaire) (p

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A source: Vatskel Elizabeth Aleksandrovna. the Lingvodidaktichesky component of educational activity of the doctor. The dissertation on competition of a scientific degree of the candidate of pedagogical sciences. Moscow - 2018. 2018

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