- Email: [email protected]
Perceived learning needs of patients with heart failure
Perceived learning needs of patients with heart failure Diane Wehby, RN, MSN, CCRN, and Phyllis S. Brenner, PhD, RN, Detroit and Livonia, Mich.
OBJECTIVE: To determine the perceived learning needs of patients with heart failure (HF) compared with identified needs by registered nurses (RNs). DESIGN: Descriptive, comparative. SETTING: Two midwestern hospitals: 1 community hospital and 1 that is part of a large, universityaffiliated, integrated health care system. SAMPLE: A convenience sample of 84 adult patients with HF from left ventricular systolic dysfunction and 84 registered nurses. OUTCOME MEASURE: The Heart Failure Learning Needs Inventory, developed for this study, was used to rate 98 individual items divided into 8 subscales suggested in the Agency for Health Care Policy and Research (AHCPR) practice guidelines. The subscales include general HF information, psychologic adaptation to illness, risk factors, medications, diet, activity, prognosis, and signs and symptoms. RESULTS: Multivariate analysis of variance was completed. The patients perceived the subscales of general HF information, risk factors, medications, prognosis, and signs and symptoms as more important to learn than the RNs did (P < .05). Patients perceived diet information as less important to learn than the RNs did (P < .05). There were no differences in the patients’ and nurses’ perceptions in the activity and psychologic subscales. The patients perceived all 8 subscales as more realistic to learn than the RNs did (P < .05). Although not in identical order, both groups ranked education related to medication and signs and symptoms as the 2 priority areas. Diet information was ranked eighth by the patients and third by the RNs. CONCLUSION: The findings are consistent with previous research supporting the overall trend that patients with HF perceived patient education to be more important and realistic to learn during hospitalization than the nurses did. Patients and nurses identified education related to signs and symptoms and medication as the 2 most important content areas. In comparison with the AHCPR clinical practice guidelines, the group of RNs studied would ascribe the additional category of signs and symptoms as essential content to be taught during hospitalization. (Heart Lung® 1999;28:31-40)
H
eart failure (HF) is a prominent health problem in the United States, with more than 400,000 new cases each year.1 As more patients survive their initial cardiac event, these
From the Department of Critical Care Services, Detroit, and the School of Nursing, Madonna University, Livonia. This study was partially funded by a research award from Detroit Medical Center–Grace Hospital. Reprint requests: Diane Wehby, Critical Care Services, Detroit Medical Center–Grace Hospital, 6071 West Outer Dr, Detroit, MI 48235. Copyright © 1999 by Mosby, Inc. 0147-9563/99/$8.00 + 0 2/1/93944
HEART & LUNG
VOL. 28, NO. 1
numbers are expected to increase. Heart failure is considered the common final pathway of all cardiac disorders. Of the nearly 3 million Americans with HF, roughly half will require hospitalization each year.2 Many of the leading causes of HF exacerbation can be prevented by nursing interventions. Learning to manage a chronic condition is the cornerstone of self-care. Patient education standards are being challenged currently by a shorter hospital length of stay (LOS). During hospitalization, patients often lack the physical and mental capacity to concentrate on learning. Earlier discharges are occurring at a time when patients and care-
31
Learning needs of patients with HF
givers are requesting more information about their disease and are struggling with the expectation of living with a chronic disease. As hospitalizations continue to shorten, nurses will be challenged to prioritize educational needs. A critical problem in attending to patient learning needs is identifying which learning needs are important and realistic to learn.3 The nurse must decide what is necessary, make sure it is learned, and leave out what is less important.4 The nurse must be able to base these decisions on research findings and not simply personal experience.
Review of the Literature In response to the high mortality and morbidity figures associated with HF, the Agency for Health Care Policy and Research (AHCPR) has identified 8 areas for improving the quality of care for patients with HF with left ventricular systolic dysfunction (LVSD). One of these recommendations, based on expert opinion versus solid evidence from research studies, is in the domain of patient education.1 The guideline recommends 8 topics for the education of patients with HF; seven of these were specifically identified as patient education topics, whereas the eighth was identified as a learning need related to adaptation to chronic illness. The topics include general HF information, psychologic factors, risk factors, medications, diet, activity, prognosis, and signs and symptoms. In regard to education, the 2 topics of medication and diet were specifically mentioned as important to discuss before discharge. Numerous authors cite examples of patients lacking basic knowledge, skills, or ability to perform basic self-care tasks.5-7 Retchin and Brown8 found that less than half of the participants in their study were instructed to observe a salt-restricted diet. These data suggest that current patient education may not achieve the desired outcomes. Patient education standards are currently being challenged by shorter hospital LOS and the fact that individuals are currently hospitalized only when severely ill.6 Earlier discharges may occur at a time when patients and caregivers are requesting more information about the disease and are struggling with the expectation of living with a chronic disease.4 Shorter hospitalizations decrease the opportunity to teach.9 This situation is exacerbated by the stress of hospitalization, which may have 1 of 2 effects on learning. To some individuals, hospitalization can provide the motivation to learn self-management strategies.5 In other individuals, anxiety interferes with learning.
32
Wehby and Brenner
A critical problem in attending to patient learning needs is identifying which learning needs are important to the patient.4 Additionally, professionals are now challenged to specifically address the 8 areas of learning needs identified by the AHCPR expert panel. The learning needs of patients with HF will become more important as the number of patients surviving their initial cardiac event increases. Five studies focused on the learning needs of medical patients with cardiac disease, specifically myocardial infarction and angina pectoris.10-14 The generalizability of all of these studies was limited due to the small sample sizes and single institution methodology. These 5 studies found that nurses’ and patients’ ratings differed in the degree of importance of patient education topics. Overall, the nurses and patients perceived all items to be relatively important to learn. Limited research has been done to determine how realistic it is to learn during hospitalization. Hagenhoff et al15 specifically addressed the perceived learning needs of patients with HF and how realistic it was to learn during hospitalization. This single-institution study examined the perception of 30 hospitalized patients with HF and 26 nurses, both licensed practical nurses (LPNs) and registered nurses (RNs), to identify the congruence between nurses and patients. Seven educational topics (general HF information, anatomy and physiology, risk factors, diet, medications, activity, and miscellaneous information) were examined. Both the nurses and the patients generally perceived that all the content areas were “quite” to “very important” to learn; however, the tendency was for patients to rate information slightly higher than the nurses did, with some being statistically significant. Patients perceived a higher importance in learning medication information than the nurses did (z = –4.84; P = .0001). This point was inconsistent with previous research, which found that nurses place a higher importance on medications than patients did.11,12 Similarly, both groups rated most content as “quite” to “very realistic” to learn during hospitalization. The small sample size limited the generalizability of the study. Theoretical framework. Key concepts from the Knowles’16,17 theory of adult learning were relevant to the development of this study. The adult’s perception of what is important should be the foundation on which the instruction plan is based. Knowles16 differentiated between the perceived (felt) needs and the needs that others have set
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
Learning needs of patients with HF
Fig 1 Research design.
for the learner (ascribed needs). The educator attempts to strike a balance between perceived and ascribed needs. Comprehensive educational plans must reflect both personal and ascribed requirements.
Purpose The purpose of this study was to investigate the perceptions of patients with HF caused by LVSD and of RNs who cared for patients with HF regarding: the degree of importance for learning patient education content, and the degree of perceived realism that the content can be learned during hospitalization. This study addressed the main limitations of previous studies in the areas of instrumentation, sample size, and diversity of sample hospitals. Hypotheses. Based on the review of the literature and the AHCPR recommendations for patient education, 16 hypotheses were posed. For each of the 8 patient education recommendations, there were 2 hypotheses. The first hypothesis for each subscale was related to the perception of the degree of importance in learning this topic. The second hypothesis for each subscale was related to the perception of the degree of realism that the educational content could be learned during hos-
HEART & LUNG
VOL. 28, NO. 1
pitalization. Based on prior research findings, directional hypotheses were used for all subscales except prognosis and signs and symptoms.
Methodology Design. To answer the research hypotheses, a comparative-descriptive, modified-replication study design was used to examine and describe the differences in perceived importance and realism between the patient and nurse groups. The research design is illustrated in Fig 1. Setting and sample. A purposive sampling technique was used in the selection of sample institutions to achieve a heterogeneous patient population. The 2 sample hospitals were selected because of their high annual number of HF admissions and their diversity in both patient demographics and LOS (Table I). At the sample hospitals, patient education is performed by staff nurses. Each hospital has a unit- or service-based clinical nurse specialist available. Neither hospital currently uses a critical pathway or other similar tool to structure patient education. It was determined that to achieve a power of 0.80, with an effect size of 0.30, a sample of 83 nurses and 83 patients was needed to test a 2-tailed hypothesis.
33
Learning needs of patients with HF
Wehby and Brenner
Table I Purposive sampling technique to achieve hospital diversity Hospital A
Hospital B
Urban Part of large integrated healthcare system
Suburban Community hospital
550 1000 4.8 Black Less than 10th grade Hypertensive heart disease
300 700 6.3 White 12th grade or higher Ischemic heart disease
Purposive sampling variable
Location Hospital type No. of beds Annual No. of HF admissions Average HF length of stay Primary patient population Primary patient educational level Primary cause of HF
Patient sample. Potential patient subjects were identified through the daily admission lists that indicated the principal diagnosis. Patient records were reviewed to determine whether subjects met the study’s inclusion criteria. Patient inclusion criteria were (1) aged 30 years or older; (2) primary diagnosis of HF, with or without other acute cardiac conditions, admitted within the last 24 to 48 hours; (3) confirmed LVSD, as evidenced by either an echocardiogram report or receipt of at least 2 medications for the treatment of LVSD, including digoxin, angiotensin converting enzyme (ACE) inhibitor, diuretic, or a vasodilator; (4) informed of the diagnosis; and (5) the ability to complete a survey instrument or an oral interview. Patients who were admitted to the intensive or cardiac care units for more than 24 hours were excluded from this study. Patients with HF caused by an acute condition may not always require as specific and extensive education as the patient with LVSD. Therefore, patients whose diagnosis of HF was primarily related to left ventricular diastolic dysfunction, valvular heart disease, anemia, fluid overload as a result of renal disease, thyroid storm, or acute arrhythmia were excluded. These patients were excluded to obtain a homogenous diagnostic group whose educational needs are addressed in the AHCPR guidelines for HF caused by LVSD. Patients who met the inclusion criteria were invited to participate on hospital day 2 or 3 until the sample size of 84 patients was achieved. Nurse sample. A convenience sample of 84 RNs from the same units and institutions participated.
34
Inclusion criteria were RNs who: (1) were not in an administrative, management, or clinical nurse specialist role; (2) were employed on the medical unit, HF unit, or telemetry unit; (3) worked at least 10 hours per week; and (4) were employed on the respective hospital’s study unit for a minimum of 3 months. Instrumentation. Modifications were made to the Congestive Heart Failure Learning Needs Inventory (CHFLNI) originally developed by Hagenhoff et al.15 The language was updated to reflect the current vocabulary used for patient education and to directly correlate with the AHCPR guidelines. In addition to a 7-item prognosis subscale, a total of 5 items were added and 5 items were deleted. The Heart Failure Learning Needs Inventory (HFLNI), a revised instrument that consists of 98 items arranged into the 8 AHCPR content areas as subscales, was used. The HFLNI consists of 2 sections. The first section contains 48 closedresponse items and 1 open-ended question that asks the participant to use a 5-point Likert scale to measure his or her perceptions of how important it was to learn each educational topic. The second section contains the same items for the participant to use to rate his or her perceptions of how realistic it is to learn the 8 content areas during hospitalization. The HFLNI was reviewed by a panel of experts who agreed with the items that had been added and deleted from the instrument and with the arrangement of the items into the subscales. The panel concluded that the instrument had face and
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
Learning needs of patients with HF
Table II Patient demographics by hospital Hospital A
Sex Age group (y) Grades of school completed
Race NYHC for functional ability
Hospital B
n
%*
n
%*
Male Female 30-50 51-70 > 71 <6 7-10 11-12 > 13
23 19 5 21 16 15 7 15 5
55 45 12 50 38 36 17 36 12
16 26 0 7 35 3 9 18 11
38 62 0 17 83 7 21 43 26
Black White, non-Hispanic
35 7
83 16
1 41
2 98
NYHC 2 NYHC 3 NYHC 4
4 26 12
10 62 29
21 21 0
50 50 0
NYHC, New York Heart Class for functional ability. *Percentages may not equal 100 because of rounding.
content validity. For the current data set, the overall alpha coefficient was 0.96. The subscales had alpha coefficients ranging from 0.87 to 0.96.
Procedures The study began after receiving approval to conduct the study from the appropriate institutional review boards. Data collection was completed by the principal investigator and 3 trained data collectors. The research packet was designed at the fourth-grade reading level so that the patients could complete it independently, unless they preferred that it be read aloud to them. Early in the data collection stage, approximately 75% of the patients requested that the instruments be read aloud to them. To minimize variability in data collection procedures, all remaining instruments were read aloud to the subsequent patients. Potential nurse subjects were invited to participate during unit-based staff meetings and shift report. The nurses were read a statement of the research purpose, study’s procedures, and the rights of human subjects. Those RNs who met the
HEART & LUNG
VOL. 28, NO. 1
eligibility criteria and volunteered to participate were given the research instruments at the end of the meetings. The nurses completed the instruments during their work shifts. They were asked to respond to the instruments based on their experiences with typical patients with HF caused by LVSD, not a specific patient.
Demographics Patient demographics. Of 102 consecutive patients with HF admitted, 18 did not participate in the study. Two patients who met the eligibility requirements declined to participate. The remaining 16 patients were excluded because they did not meet the eligibility criteria. The mean patient age was 71.8 years (SD = 12.86), with a range of 33 to 92 years. Women accounted for 54% (n = 45) of the patient population; 46% (n = 39) were men. A total of 61 (72.6%) had chronic HF, whereas 23 (27.4%) were newly diagnosed. Because of purposive sampling, significant differences were noted between the patient samples at each institution in the variables of race, age, and severity of illness (Table II).
35
Learning needs of patients with HF
Wehby and Brenner
Table III Perceived importance on subscales between nurses and patients Subscale
Group
M
SD
F
General HF information
Patients Nurses
32.19 29.29
4.62 4.96
15.42*
Psychologic
Patients Nurses
25.64 24.32
5.89 5.03
2.44
Risk factors
Patients Nurses
13.55 12.56
2.64 2.61
5.95*
Medications
Patients Nurses
24.19 22.80
2.67 3.04
9.94*
Diet
Patients Nurses
40.36 42.82
8.64 7.38
3.95*
Activity
Patients Nurses
21.81 20.75
4.00 3.84
3.95
Prognosis
Patients Nurses
30.73 28.02
4.97 5.80
10.52**
Signs and symptoms
Patients Nurses
24.08 23.25
3.07 2.99
3.18*
*P < .05, 1-tailed. **P < .05, 2-tailed.
Nurse demographics. The nurse subjects (n = 84) had a mean age of 39 years (SD = 10.54), with a range of 23 to 68 years. Of the respondents, 98.8% were women. More than half (n = 43) had obtained a minimum of a bachelor’s degree. Nine nurses held certification in medical-surgical nursing and 1 held CCRN certification in critical care. The total years in nursing practice ranged from 0.25 to 31 years (M = 13 years; SD = 9.1). Forty-seven nurses (57%) reported attending a seminar or course on HF education. Most (80%) reported caring for patients with HF either frequently or on a daily basis.
Study Results To answer the proposed research hypotheses, multivariate analysis of variances (MANOVA) were done, for the 8 importance subscales and the 8 realism subscales. Tables III and IV summarize the findings. The MANOVA of the importance subscales indicated that 6 of the 8 subscales contributed significantly to the overall Wilks’ lambda (F = 7.08; P <
36
.001). The patients perceived that the subscales of general HF information, risk factors, medications, prognosis, and signs and symptoms were more important to learn than the nurses did. The patients perceived diet information as less important than the nurses did. There were no differences in the perceptions of the patients and nurses in the activity and psychologic subscales. The MANOVA of the realism subscales indicated that all 8 of the subscales contributed to the overall Wilks’ lamda (F = 9.25; P < .001). The patients perceived all 8 of the subscales as more realistic to learn during hospitalization than the nurses did. Although statistically significant differences were found in most of the subscale scores (14 of 16), the overall mean ratings for both the patients and nurses were within the upper 2 ratings of the Likert scale in the area of importance. In the area of perceived realism, the patients continued to rate items in the upper 2 ratings of the Likert scale. The nurses, however, rated items as slightly less realis-
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
Learning needs of patients with HF
Table IV Perceived realism on subscales between nurses and patients Subscale
Group
M
SD
F
General HF information
Patients Nurses
30.61 24.99
6.74 6.11
32.08*
Psychologic
Patients Nurses
25.63 19.80
5.79 6.26
39.34*
Risk factors
Patients Nurses
12.86 10.25
3.04 3.40
27.46*
Medications
Patients Nurses
22.86 18.94
4.16 4.71
32.64*
Diet
Patients Nurses
40.45 36.15
8.89 9.90
8.76*
Activity
Patients Nurses
21.24 17.25
4.47 5.12
28.90**
Prognosis
Patients Nurses
29.99 22.71
5.80 7.77
47.74**
Signs and symptoms
Patients Nurses
23.45 20.33
3.88 4.64
22.36*
* P < .05, 1-tailed. **P < .05, 2-tailed.
tic to learn than the patients did. The nurses’ ratings generally placed the subscale means into the third-rank category on the Likert scale. Subscale rankings. The subscales were ranked according to their mean scores. Although the patients and nurses placed the medication and signs and symptoms subscales in the top 2 areas of importance and realism, they disagreed on the rank ordering. The nurses ranked prognosis information as least important and realistic, whereas the patients placed diet information last and prognosis as fifth in both realism and importance (Tables V and VI). Patient cohort. Because of the intended heterogeneous patient population, t tests were computed to determine whether there were significant differences between the patient subgroups (Hospital A and Hospital B) on subscale responses. Despite the heterogenous patient populations sampled, the scores for the degree of perceived importance were consistent, with 1 exception. The only signifi-
HEART & LUNG
VOL. 28, NO. 1
cant difference—F = 4.53, P = .04—was in the prognosis subscale. Age and decision making regarding end-of-life issues may have influenced how the individual items on the prognosis subscale were ranked. Although significant differences in realism were only found in the risk factors (F = 5.95; P < .02) and medications (F = 7.10, P < .01) subscales, the general trend was the patients at Hospital B perceived the subscales to be more realistic to learn during hospitalization. This may be attributed to the longer length of stay at Hospital B (6.3 days) compared with Hospital A (4.8 days). Nurse cohort. There were no significant differences in the degree of perceived importance or realism found between the nurse cohorts. These results are not surprising, considering the homogeneity in the nurses across the 2 institutions. These findings are inconsistent with previous studies, which suggested that the prioritization of learning needs may be, in part, related to the specific
37
Learning needs of patients with HF
Wehby and Brenner
Table V Rank order of perceived degree of importance by subscale mean scores Patient Rank
Subscale
1 2 3 4 5 6 7 8
Medications Signs/symptoms General information Risk factors Prognosis Activity Psychologic Diet
Nurse M (SD)
4.84 4.82 4.60 4.52 4.39 4.36 4.27 4.04
(0.53) (0.61) (0.66) (0.88) (0.71) (0.80) (0.98) (0.86)
Rank
Category
1 2 3 4 5 6 7 8
Signs/symptoms Medications Diet Risk factors General information Activity Psychologic Prognosis
M (SD)
4.65 4.56 4.28 4.19 4.18 4.15 4.05 4.00
(0.60) (0.61) (0.74) (0.87) (0.71) (0.77) (0.84) (0.83)
Table VI Rank order of perceived degree of realism of subscale mean scores Patient Rank
Subscale
1 2 3 4 5 6 7 8
Signs/symptoms Medications General information Risk factors Prognosis Psychologic Activity Diet
Nurse M (SD)
4.69 4.57 4.37 4.29 4.28 4.27 4.25 4.05
(0.78) (0.83) (0.96) (1.01) (0.83) (0.96) (0.89) (0.89)
hospital’s standards of care.6,8 The findings of this study may reflect a trend toward standardization of care—a desired intent of the AHCPR clinical practice guidelines. Patient subgroups. An important subgroup in this study included 23 (27.4%) patients newly diagnosed with HF during this hospitalization. There were no statistically significant differences in the perceptions of the degree of importance between the patients with a new diagnosis of HF compared with those experiencing an exacerbation of chronic HF. These findings are consistent with those reported by Hagenhoff et al,15 in that perceived educational needs are similar for the patient with a new diagnosis and those experiencing an exacerbation of a chronic illness.
Strengths and Limitations The main strength of this study is that the patients selected for inclusion were specifically
38
Rank
Category
1 2 3 4 5 6 7 8
Signs/symptoms Medications Diet General information Activity Risk factors Psychologic Prognosis
M (SD)
4.07 3.79 3.62 3.57 3.45 3.42 3.30 3.24
(0.93) (0.94) (0.99) (0.87) (1.02) (1.13) (1.04) (1.10)
patients with HF caused by LVSD and represented a homogeneous diagnostic grouping not previously studied. Another strength is that the sample size was adequate to detect a relatively small effect. Diverse hospitals were used to obtain a heterogeneous HF population and to minimize the effect of nursing standards or demographics on the responses. The findings of this study should be interpreted in view of several limitations. This study’s generalizability is limited to older white and younger black patients with HF caused by LVSD. In that there were no significant differences between these 2 subgroups, the generalizability may be even broader. This study did not assess baseline knowledge of HF self-care management, nor did this study address the actual acquisition or retention of patient education content. Furthermore, the nurses had been asked to rank items based on the HF population in aggregate. Responses
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
might have been different if matched pairs were studied.
Suggestions for Further Research Further research should assess the perceived learning needs of patients with HF throughout the care continuum to determine the effect of living with a chronic disease on the perceived importance of learning content. Future studies could be designed to determine the knowledge base of patients with HF experiencing decompensation compared with those with compensated HF. An investigation could be conducted to determine the information-seeking styles of patients with HF. Eventually, research needs to be conducted to determine the best methods to achieve rapid patient knowledge acquisition. Research is needed to address alternative methods such as videos in educating the low literacy patient.
Discussion and Implications for Practice The findings of this study provide information concerning the perceived learning needs of patients hospitalized with HF. They are consistent with previous research, indicating that patients with HF perceive patient education as “moderately important” to “very important” and “realistic” to “very realistic” to learn during hospitalization. The overall trend was that patients perceived all topics to be more important and realistic to learn during hospitalization than the nurses did. The findings of this study do not wholly support the consensus opinion of the panel who formulated the AHCPR guideline for the treatment of HF caused by LVSD. The AHCPR panel explicitly stated that diet and medications teaching should be conducted before hospital discharge.1 The patient participants, presumably based on their lived experience of having HF, ranked medications as the most important topic, whereas the nurses ranked it second after signs and symptoms. Patients ranked signs and symptoms second and placed diet information as eighth, whereas the nurses ranked diet third. Thus, in both groups, signs and symptoms were ranked higher than the diet information. In comparison with the AHCPR recommendations, this group of nurses would ascribe education of signs and symptoms, medications, and diet as the 3 most important and realistic areas to learn during hospitalization. Patients also indicated a need for information on signs and symptoms. This study thus suggests the addition of a third category of essential content related to signs and symp-
HEART & LUNG
VOL. 28, NO. 1
Learning needs of patients with HF
toms during hospitalization. To improve health outcomes and decrease the necessity for hospitalization, it is essential that patients be able to monitor their own symptoms to ensure early intervention for exacerbations. The greatest risk for rehospitalization for HF is during the immediate postdischarge period.18 Providing patients with the knowledge of signs and symptoms before discharge will allow important self-care monitoring between follow-up appointments. The patients ranked diet education as the last category in both importance and realism to learn during hospitalization. The nurses, however, placed the diet subscale as third in importance behind signs and symptoms and medications in both importance and realism. This demonstrates that nurses who have experience caring for patients with HF caused by LVSD recognize the importance of the diet in the management of HF and as such would prioritize it as an ascribed learning need. Patients placed less importance and realism on the dietary content. This may be a reflection that dietary habits are deeply ingrained and patients may be less interested in changing a lifetime of eating habits. Diet may not be recognized by patients as an important component in managing HF. Specifically, patients may not fully appreciate the relationship of sodium intake with fluid retention. Therefore, patients may not recognize the importance of daily weights in detecting fluid retention before the development of clinical symptoms. The literature suggests that noncompliance with a low-sodium diet is often associated with HF exacerbations.18 Even though diet was ranked lowest by patients, the scores indicated that patients still perceived that this information was “moderately important” and “moderately realistic” to learn during hospitalization. The study findings support the premise that patient education is a vital component of nursing care during hospitalization. As hospitalizations continue to shorten, nurses will be challenged to continue to meet their patient’s educational needs. Nurses need to be aware that, although they may perceive that patient education items are less realistic to learn, patients are eager to master content and believe that it is realistic to learn during hospitalization. Perhaps nurses do a disservice to patients by postponing educational content based on the assumption that it is not realistic for patients to learn. Although learning barriers are present during hospitalization, this study supports the notion that hospitalization may be a motivator and oppor-
39
Learning needs of patients with HF
tunity for obtaining necessary information regarding one’s disease. The findings of this study provide the basis for the development of a comprehensive educational plan for patients with HF. This plan should provide education with use of a variety of media including video, printed materials, discussions, and opportunities to demonstrate self-care management skills. The 8 subscales of the HFLNI are useful for the nurse as a method to compartmentalize the large amount of content into manageable sections. The use of a critical pathway or a similar tool incorporating these topics and individual items contained on the HFLNI could allow for an educational continuum to be developed that transcends hospital- and community-based care. Overall, the nurses and patients were in disagreement on 11 of the 16 subscales, thus indicating an imbalance between the perceived and ascribed needs for the HF population relative to the degree of perceived importance and realism. Nurses must attempt to strike a balance between the perceived needs of the patient and ascribed needs based on the recommendations of the AHCPR. As hospitalizations continue to shorten, nurses across the care continuum will be able to use this information to set priorities for patient education. The educational plan could be implemented at the time of diagnosis, regardless of the setting. Educational objectives can be developed so that the nurse will be able to ensure that a baseline knowledge of HF selfcare management skills have been learned before discharge. When a patient is discharged without mastering the essential knowledge and skills, a plan must be established for acquiring the information in the community setting. For all patients, a seamless health care delivery model would be ideal, because education needs frequent reenforcement to have an impact on behavioral choices and to result in enduring behavioral changes.
40
Wehby and Brenner
REFERENCES 1. Konstam M, Dracup K, Baker D, et al. Clinical Practice Guideline No 11: Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Rockville (MD): Agency for Health Care Policy and Research, Public Health Services, US Depart of Health and Human Services; 1994. AHCPR Publication No: 94-0612. 2. Quall S. Cardiovascular nursing: holistic practice. St. Louis: Mosby–Yearbook; 1992. 3. Lorenz R, Pichert J, Schlundt D, Boswell E. Teaching training for health professionals: effects on immediate recall by surgery patients. Teach Learn Med 1989;1:26-30. 4. Bubela N, Galloway S, McCay E, McKibbon A, Pringled D, Ros E, et al. The patient learning needs scale: reliability and validity. J Adv Nurs 1990;15:1181-7. 5. Grady K, Buckley D, Cisar N, Fink N, Ryan S. Patient perception of cardiovascular surgical patient education. Heart Lung 1988;17:349-54. 6. Kegel L. Advanced practice nurses can refine the management of heart failure. Clin Nurse Spec 1995;9:76-81. 7. Lorenz R. Teaching skills of health professionals. Diabetes Educ 1989;15:149-52. 8. Retchin S, Brown B. Elderly patients with congestive heart failure under prepaid care. Am J Med 1991;90:236-42. 9. Rifas E, Morris R, Grandy R. Innovative approach to patient education. Nurs Outlook 1994;42:214-6. 10. Chan V. Content areas for cardiac teaching: patients’ perceptions of the importance of teaching content after myocardial infarction. J Adv Nurs 1990;15:1139-45. 11. Gerard P, Peterson L. Learning needs of cardiac patients. Cardiovasc Nurs 1984;20:7-11. 12. Karlik B, Yarcheski A. Learning needs of cardiac patients: a partial replication study. Heart Lung 1987;16:544-51. 13. Karlik B, Yarcheski A, Braun J, Wu M. Learning needs of patients with angina: an extension study. J Cardiovasc Nurs 1990; 4:70-82. 14. Wingate S. Post-MI patients’ perception of their learning needs. DCCN 1990;9:112-8. 15. Hagenhoff B, Feutz C, Conn V, Sagehorn K, Moranville-Hunziker M. Patient education needs as reported by congestive heart failure patients and their nurses. J Adv Nurs 1994;19:68590. 16. Knowles M. The adult learner: a neglected species. 2nd ed. Houston: Gulf Publishing; 1978. 17. Knowles M. Introduction: the art and science of helping adults learn. In: Knowles M & Associates, editors. Andragogy in action: applying modern principles of adult learning. San Francisco: Jossey-Bass; 1984.p.1-22. 18. Vinson J, Rich M, Sperry J, et al. Early readmissions of elderly patients with congestive heart failure. J Am Geriatr Soc 1990;38:1290-95.
JANUARY/FEBRUARY 1999
HEART & LUNG
OBJECTIVE: To determine the perceived learning needs of patients with heart failure (HF) compared with identified needs by registered nurses (RNs). DESIGN: Descriptive, comparative. SETTING: Two midwestern hospitals: 1 community hospital and 1 that is part of a large, universityaffiliated, integrated health care system. SAMPLE: A convenience sample of 84 adult patients with HF from left ventricular systolic dysfunction and 84 registered nurses. OUTCOME MEASURE: The Heart Failure Learning Needs Inventory, developed for this study, was used to rate 98 individual items divided into 8 subscales suggested in the Agency for Health Care Policy and Research (AHCPR) practice guidelines. The subscales include general HF information, psychologic adaptation to illness, risk factors, medications, diet, activity, prognosis, and signs and symptoms. RESULTS: Multivariate analysis of variance was completed. The patients perceived the subscales of general HF information, risk factors, medications, prognosis, and signs and symptoms as more important to learn than the RNs did (P < .05). Patients perceived diet information as less important to learn than the RNs did (P < .05). There were no differences in the patients’ and nurses’ perceptions in the activity and psychologic subscales. The patients perceived all 8 subscales as more realistic to learn than the RNs did (P < .05). Although not in identical order, both groups ranked education related to medication and signs and symptoms as the 2 priority areas. Diet information was ranked eighth by the patients and third by the RNs. CONCLUSION: The findings are consistent with previous research supporting the overall trend that patients with HF perceived patient education to be more important and realistic to learn during hospitalization than the nurses did. Patients and nurses identified education related to signs and symptoms and medication as the 2 most important content areas. In comparison with the AHCPR clinical practice guidelines, the group of RNs studied would ascribe the additional category of signs and symptoms as essential content to be taught during hospitalization. (Heart Lung® 1999;28:31-40)
H
eart failure (HF) is a prominent health problem in the United States, with more than 400,000 new cases each year.1 As more patients survive their initial cardiac event, these
From the Department of Critical Care Services, Detroit, and the School of Nursing, Madonna University, Livonia. This study was partially funded by a research award from Detroit Medical Center–Grace Hospital. Reprint requests: Diane Wehby, Critical Care Services, Detroit Medical Center–Grace Hospital, 6071 West Outer Dr, Detroit, MI 48235. Copyright © 1999 by Mosby, Inc. 0147-9563/99/$8.00 + 0 2/1/93944
HEART & LUNG
VOL. 28, NO. 1
numbers are expected to increase. Heart failure is considered the common final pathway of all cardiac disorders. Of the nearly 3 million Americans with HF, roughly half will require hospitalization each year.2 Many of the leading causes of HF exacerbation can be prevented by nursing interventions. Learning to manage a chronic condition is the cornerstone of self-care. Patient education standards are being challenged currently by a shorter hospital length of stay (LOS). During hospitalization, patients often lack the physical and mental capacity to concentrate on learning. Earlier discharges are occurring at a time when patients and care-
31
Learning needs of patients with HF
givers are requesting more information about their disease and are struggling with the expectation of living with a chronic disease. As hospitalizations continue to shorten, nurses will be challenged to prioritize educational needs. A critical problem in attending to patient learning needs is identifying which learning needs are important and realistic to learn.3 The nurse must decide what is necessary, make sure it is learned, and leave out what is less important.4 The nurse must be able to base these decisions on research findings and not simply personal experience.
Review of the Literature In response to the high mortality and morbidity figures associated with HF, the Agency for Health Care Policy and Research (AHCPR) has identified 8 areas for improving the quality of care for patients with HF with left ventricular systolic dysfunction (LVSD). One of these recommendations, based on expert opinion versus solid evidence from research studies, is in the domain of patient education.1 The guideline recommends 8 topics for the education of patients with HF; seven of these were specifically identified as patient education topics, whereas the eighth was identified as a learning need related to adaptation to chronic illness. The topics include general HF information, psychologic factors, risk factors, medications, diet, activity, prognosis, and signs and symptoms. In regard to education, the 2 topics of medication and diet were specifically mentioned as important to discuss before discharge. Numerous authors cite examples of patients lacking basic knowledge, skills, or ability to perform basic self-care tasks.5-7 Retchin and Brown8 found that less than half of the participants in their study were instructed to observe a salt-restricted diet. These data suggest that current patient education may not achieve the desired outcomes. Patient education standards are currently being challenged by shorter hospital LOS and the fact that individuals are currently hospitalized only when severely ill.6 Earlier discharges may occur at a time when patients and caregivers are requesting more information about the disease and are struggling with the expectation of living with a chronic disease.4 Shorter hospitalizations decrease the opportunity to teach.9 This situation is exacerbated by the stress of hospitalization, which may have 1 of 2 effects on learning. To some individuals, hospitalization can provide the motivation to learn self-management strategies.5 In other individuals, anxiety interferes with learning.
32
Wehby and Brenner
A critical problem in attending to patient learning needs is identifying which learning needs are important to the patient.4 Additionally, professionals are now challenged to specifically address the 8 areas of learning needs identified by the AHCPR expert panel. The learning needs of patients with HF will become more important as the number of patients surviving their initial cardiac event increases. Five studies focused on the learning needs of medical patients with cardiac disease, specifically myocardial infarction and angina pectoris.10-14 The generalizability of all of these studies was limited due to the small sample sizes and single institution methodology. These 5 studies found that nurses’ and patients’ ratings differed in the degree of importance of patient education topics. Overall, the nurses and patients perceived all items to be relatively important to learn. Limited research has been done to determine how realistic it is to learn during hospitalization. Hagenhoff et al15 specifically addressed the perceived learning needs of patients with HF and how realistic it was to learn during hospitalization. This single-institution study examined the perception of 30 hospitalized patients with HF and 26 nurses, both licensed practical nurses (LPNs) and registered nurses (RNs), to identify the congruence between nurses and patients. Seven educational topics (general HF information, anatomy and physiology, risk factors, diet, medications, activity, and miscellaneous information) were examined. Both the nurses and the patients generally perceived that all the content areas were “quite” to “very important” to learn; however, the tendency was for patients to rate information slightly higher than the nurses did, with some being statistically significant. Patients perceived a higher importance in learning medication information than the nurses did (z = –4.84; P = .0001). This point was inconsistent with previous research, which found that nurses place a higher importance on medications than patients did.11,12 Similarly, both groups rated most content as “quite” to “very realistic” to learn during hospitalization. The small sample size limited the generalizability of the study. Theoretical framework. Key concepts from the Knowles’16,17 theory of adult learning were relevant to the development of this study. The adult’s perception of what is important should be the foundation on which the instruction plan is based. Knowles16 differentiated between the perceived (felt) needs and the needs that others have set
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
Learning needs of patients with HF
Fig 1 Research design.
for the learner (ascribed needs). The educator attempts to strike a balance between perceived and ascribed needs. Comprehensive educational plans must reflect both personal and ascribed requirements.
Purpose The purpose of this study was to investigate the perceptions of patients with HF caused by LVSD and of RNs who cared for patients with HF regarding: the degree of importance for learning patient education content, and the degree of perceived realism that the content can be learned during hospitalization. This study addressed the main limitations of previous studies in the areas of instrumentation, sample size, and diversity of sample hospitals. Hypotheses. Based on the review of the literature and the AHCPR recommendations for patient education, 16 hypotheses were posed. For each of the 8 patient education recommendations, there were 2 hypotheses. The first hypothesis for each subscale was related to the perception of the degree of importance in learning this topic. The second hypothesis for each subscale was related to the perception of the degree of realism that the educational content could be learned during hos-
HEART & LUNG
VOL. 28, NO. 1
pitalization. Based on prior research findings, directional hypotheses were used for all subscales except prognosis and signs and symptoms.
Methodology Design. To answer the research hypotheses, a comparative-descriptive, modified-replication study design was used to examine and describe the differences in perceived importance and realism between the patient and nurse groups. The research design is illustrated in Fig 1. Setting and sample. A purposive sampling technique was used in the selection of sample institutions to achieve a heterogeneous patient population. The 2 sample hospitals were selected because of their high annual number of HF admissions and their diversity in both patient demographics and LOS (Table I). At the sample hospitals, patient education is performed by staff nurses. Each hospital has a unit- or service-based clinical nurse specialist available. Neither hospital currently uses a critical pathway or other similar tool to structure patient education. It was determined that to achieve a power of 0.80, with an effect size of 0.30, a sample of 83 nurses and 83 patients was needed to test a 2-tailed hypothesis.
33
Learning needs of patients with HF
Wehby and Brenner
Table I Purposive sampling technique to achieve hospital diversity Hospital A
Hospital B
Urban Part of large integrated healthcare system
Suburban Community hospital
550 1000 4.8 Black Less than 10th grade Hypertensive heart disease
300 700 6.3 White 12th grade or higher Ischemic heart disease
Purposive sampling variable
Location Hospital type No. of beds Annual No. of HF admissions Average HF length of stay Primary patient population Primary patient educational level Primary cause of HF
Patient sample. Potential patient subjects were identified through the daily admission lists that indicated the principal diagnosis. Patient records were reviewed to determine whether subjects met the study’s inclusion criteria. Patient inclusion criteria were (1) aged 30 years or older; (2) primary diagnosis of HF, with or without other acute cardiac conditions, admitted within the last 24 to 48 hours; (3) confirmed LVSD, as evidenced by either an echocardiogram report or receipt of at least 2 medications for the treatment of LVSD, including digoxin, angiotensin converting enzyme (ACE) inhibitor, diuretic, or a vasodilator; (4) informed of the diagnosis; and (5) the ability to complete a survey instrument or an oral interview. Patients who were admitted to the intensive or cardiac care units for more than 24 hours were excluded from this study. Patients with HF caused by an acute condition may not always require as specific and extensive education as the patient with LVSD. Therefore, patients whose diagnosis of HF was primarily related to left ventricular diastolic dysfunction, valvular heart disease, anemia, fluid overload as a result of renal disease, thyroid storm, or acute arrhythmia were excluded. These patients were excluded to obtain a homogenous diagnostic group whose educational needs are addressed in the AHCPR guidelines for HF caused by LVSD. Patients who met the inclusion criteria were invited to participate on hospital day 2 or 3 until the sample size of 84 patients was achieved. Nurse sample. A convenience sample of 84 RNs from the same units and institutions participated.
34
Inclusion criteria were RNs who: (1) were not in an administrative, management, or clinical nurse specialist role; (2) were employed on the medical unit, HF unit, or telemetry unit; (3) worked at least 10 hours per week; and (4) were employed on the respective hospital’s study unit for a minimum of 3 months. Instrumentation. Modifications were made to the Congestive Heart Failure Learning Needs Inventory (CHFLNI) originally developed by Hagenhoff et al.15 The language was updated to reflect the current vocabulary used for patient education and to directly correlate with the AHCPR guidelines. In addition to a 7-item prognosis subscale, a total of 5 items were added and 5 items were deleted. The Heart Failure Learning Needs Inventory (HFLNI), a revised instrument that consists of 98 items arranged into the 8 AHCPR content areas as subscales, was used. The HFLNI consists of 2 sections. The first section contains 48 closedresponse items and 1 open-ended question that asks the participant to use a 5-point Likert scale to measure his or her perceptions of how important it was to learn each educational topic. The second section contains the same items for the participant to use to rate his or her perceptions of how realistic it is to learn the 8 content areas during hospitalization. The HFLNI was reviewed by a panel of experts who agreed with the items that had been added and deleted from the instrument and with the arrangement of the items into the subscales. The panel concluded that the instrument had face and
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
Learning needs of patients with HF
Table II Patient demographics by hospital Hospital A
Sex Age group (y) Grades of school completed
Race NYHC for functional ability
Hospital B
n
%*
n
%*
Male Female 30-50 51-70 > 71 <6 7-10 11-12 > 13
23 19 5 21 16 15 7 15 5
55 45 12 50 38 36 17 36 12
16 26 0 7 35 3 9 18 11
38 62 0 17 83 7 21 43 26
Black White, non-Hispanic
35 7
83 16
1 41
2 98
NYHC 2 NYHC 3 NYHC 4
4 26 12
10 62 29
21 21 0
50 50 0
NYHC, New York Heart Class for functional ability. *Percentages may not equal 100 because of rounding.
content validity. For the current data set, the overall alpha coefficient was 0.96. The subscales had alpha coefficients ranging from 0.87 to 0.96.
Procedures The study began after receiving approval to conduct the study from the appropriate institutional review boards. Data collection was completed by the principal investigator and 3 trained data collectors. The research packet was designed at the fourth-grade reading level so that the patients could complete it independently, unless they preferred that it be read aloud to them. Early in the data collection stage, approximately 75% of the patients requested that the instruments be read aloud to them. To minimize variability in data collection procedures, all remaining instruments were read aloud to the subsequent patients. Potential nurse subjects were invited to participate during unit-based staff meetings and shift report. The nurses were read a statement of the research purpose, study’s procedures, and the rights of human subjects. Those RNs who met the
HEART & LUNG
VOL. 28, NO. 1
eligibility criteria and volunteered to participate were given the research instruments at the end of the meetings. The nurses completed the instruments during their work shifts. They were asked to respond to the instruments based on their experiences with typical patients with HF caused by LVSD, not a specific patient.
Demographics Patient demographics. Of 102 consecutive patients with HF admitted, 18 did not participate in the study. Two patients who met the eligibility requirements declined to participate. The remaining 16 patients were excluded because they did not meet the eligibility criteria. The mean patient age was 71.8 years (SD = 12.86), with a range of 33 to 92 years. Women accounted for 54% (n = 45) of the patient population; 46% (n = 39) were men. A total of 61 (72.6%) had chronic HF, whereas 23 (27.4%) were newly diagnosed. Because of purposive sampling, significant differences were noted between the patient samples at each institution in the variables of race, age, and severity of illness (Table II).
35
Learning needs of patients with HF
Wehby and Brenner
Table III Perceived importance on subscales between nurses and patients Subscale
Group
M
SD
F
General HF information
Patients Nurses
32.19 29.29
4.62 4.96
15.42*
Psychologic
Patients Nurses
25.64 24.32
5.89 5.03
2.44
Risk factors
Patients Nurses
13.55 12.56
2.64 2.61
5.95*
Medications
Patients Nurses
24.19 22.80
2.67 3.04
9.94*
Diet
Patients Nurses
40.36 42.82
8.64 7.38
3.95*
Activity
Patients Nurses
21.81 20.75
4.00 3.84
3.95
Prognosis
Patients Nurses
30.73 28.02
4.97 5.80
10.52**
Signs and symptoms
Patients Nurses
24.08 23.25
3.07 2.99
3.18*
*P < .05, 1-tailed. **P < .05, 2-tailed.
Nurse demographics. The nurse subjects (n = 84) had a mean age of 39 years (SD = 10.54), with a range of 23 to 68 years. Of the respondents, 98.8% were women. More than half (n = 43) had obtained a minimum of a bachelor’s degree. Nine nurses held certification in medical-surgical nursing and 1 held CCRN certification in critical care. The total years in nursing practice ranged from 0.25 to 31 years (M = 13 years; SD = 9.1). Forty-seven nurses (57%) reported attending a seminar or course on HF education. Most (80%) reported caring for patients with HF either frequently or on a daily basis.
Study Results To answer the proposed research hypotheses, multivariate analysis of variances (MANOVA) were done, for the 8 importance subscales and the 8 realism subscales. Tables III and IV summarize the findings. The MANOVA of the importance subscales indicated that 6 of the 8 subscales contributed significantly to the overall Wilks’ lambda (F = 7.08; P <
36
.001). The patients perceived that the subscales of general HF information, risk factors, medications, prognosis, and signs and symptoms were more important to learn than the nurses did. The patients perceived diet information as less important than the nurses did. There were no differences in the perceptions of the patients and nurses in the activity and psychologic subscales. The MANOVA of the realism subscales indicated that all 8 of the subscales contributed to the overall Wilks’ lamda (F = 9.25; P < .001). The patients perceived all 8 of the subscales as more realistic to learn during hospitalization than the nurses did. Although statistically significant differences were found in most of the subscale scores (14 of 16), the overall mean ratings for both the patients and nurses were within the upper 2 ratings of the Likert scale in the area of importance. In the area of perceived realism, the patients continued to rate items in the upper 2 ratings of the Likert scale. The nurses, however, rated items as slightly less realis-
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
Learning needs of patients with HF
Table IV Perceived realism on subscales between nurses and patients Subscale
Group
M
SD
F
General HF information
Patients Nurses
30.61 24.99
6.74 6.11
32.08*
Psychologic
Patients Nurses
25.63 19.80
5.79 6.26
39.34*
Risk factors
Patients Nurses
12.86 10.25
3.04 3.40
27.46*
Medications
Patients Nurses
22.86 18.94
4.16 4.71
32.64*
Diet
Patients Nurses
40.45 36.15
8.89 9.90
8.76*
Activity
Patients Nurses
21.24 17.25
4.47 5.12
28.90**
Prognosis
Patients Nurses
29.99 22.71
5.80 7.77
47.74**
Signs and symptoms
Patients Nurses
23.45 20.33
3.88 4.64
22.36*
* P < .05, 1-tailed. **P < .05, 2-tailed.
tic to learn than the patients did. The nurses’ ratings generally placed the subscale means into the third-rank category on the Likert scale. Subscale rankings. The subscales were ranked according to their mean scores. Although the patients and nurses placed the medication and signs and symptoms subscales in the top 2 areas of importance and realism, they disagreed on the rank ordering. The nurses ranked prognosis information as least important and realistic, whereas the patients placed diet information last and prognosis as fifth in both realism and importance (Tables V and VI). Patient cohort. Because of the intended heterogeneous patient population, t tests were computed to determine whether there were significant differences between the patient subgroups (Hospital A and Hospital B) on subscale responses. Despite the heterogenous patient populations sampled, the scores for the degree of perceived importance were consistent, with 1 exception. The only signifi-
HEART & LUNG
VOL. 28, NO. 1
cant difference—F = 4.53, P = .04—was in the prognosis subscale. Age and decision making regarding end-of-life issues may have influenced how the individual items on the prognosis subscale were ranked. Although significant differences in realism were only found in the risk factors (F = 5.95; P < .02) and medications (F = 7.10, P < .01) subscales, the general trend was the patients at Hospital B perceived the subscales to be more realistic to learn during hospitalization. This may be attributed to the longer length of stay at Hospital B (6.3 days) compared with Hospital A (4.8 days). Nurse cohort. There were no significant differences in the degree of perceived importance or realism found between the nurse cohorts. These results are not surprising, considering the homogeneity in the nurses across the 2 institutions. These findings are inconsistent with previous studies, which suggested that the prioritization of learning needs may be, in part, related to the specific
37
Learning needs of patients with HF
Wehby and Brenner
Table V Rank order of perceived degree of importance by subscale mean scores Patient Rank
Subscale
1 2 3 4 5 6 7 8
Medications Signs/symptoms General information Risk factors Prognosis Activity Psychologic Diet
Nurse M (SD)
4.84 4.82 4.60 4.52 4.39 4.36 4.27 4.04
(0.53) (0.61) (0.66) (0.88) (0.71) (0.80) (0.98) (0.86)
Rank
Category
1 2 3 4 5 6 7 8
Signs/symptoms Medications Diet Risk factors General information Activity Psychologic Prognosis
M (SD)
4.65 4.56 4.28 4.19 4.18 4.15 4.05 4.00
(0.60) (0.61) (0.74) (0.87) (0.71) (0.77) (0.84) (0.83)
Table VI Rank order of perceived degree of realism of subscale mean scores Patient Rank
Subscale
1 2 3 4 5 6 7 8
Signs/symptoms Medications General information Risk factors Prognosis Psychologic Activity Diet
Nurse M (SD)
4.69 4.57 4.37 4.29 4.28 4.27 4.25 4.05
(0.78) (0.83) (0.96) (1.01) (0.83) (0.96) (0.89) (0.89)
hospital’s standards of care.6,8 The findings of this study may reflect a trend toward standardization of care—a desired intent of the AHCPR clinical practice guidelines. Patient subgroups. An important subgroup in this study included 23 (27.4%) patients newly diagnosed with HF during this hospitalization. There were no statistically significant differences in the perceptions of the degree of importance between the patients with a new diagnosis of HF compared with those experiencing an exacerbation of chronic HF. These findings are consistent with those reported by Hagenhoff et al,15 in that perceived educational needs are similar for the patient with a new diagnosis and those experiencing an exacerbation of a chronic illness.
Strengths and Limitations The main strength of this study is that the patients selected for inclusion were specifically
38
Rank
Category
1 2 3 4 5 6 7 8
Signs/symptoms Medications Diet General information Activity Risk factors Psychologic Prognosis
M (SD)
4.07 3.79 3.62 3.57 3.45 3.42 3.30 3.24
(0.93) (0.94) (0.99) (0.87) (1.02) (1.13) (1.04) (1.10)
patients with HF caused by LVSD and represented a homogeneous diagnostic grouping not previously studied. Another strength is that the sample size was adequate to detect a relatively small effect. Diverse hospitals were used to obtain a heterogeneous HF population and to minimize the effect of nursing standards or demographics on the responses. The findings of this study should be interpreted in view of several limitations. This study’s generalizability is limited to older white and younger black patients with HF caused by LVSD. In that there were no significant differences between these 2 subgroups, the generalizability may be even broader. This study did not assess baseline knowledge of HF self-care management, nor did this study address the actual acquisition or retention of patient education content. Furthermore, the nurses had been asked to rank items based on the HF population in aggregate. Responses
JANUARY/FEBRUARY 1999
HEART & LUNG
Wehby and Brenner
might have been different if matched pairs were studied.
Suggestions for Further Research Further research should assess the perceived learning needs of patients with HF throughout the care continuum to determine the effect of living with a chronic disease on the perceived importance of learning content. Future studies could be designed to determine the knowledge base of patients with HF experiencing decompensation compared with those with compensated HF. An investigation could be conducted to determine the information-seeking styles of patients with HF. Eventually, research needs to be conducted to determine the best methods to achieve rapid patient knowledge acquisition. Research is needed to address alternative methods such as videos in educating the low literacy patient.
Discussion and Implications for Practice The findings of this study provide information concerning the perceived learning needs of patients hospitalized with HF. They are consistent with previous research, indicating that patients with HF perceive patient education as “moderately important” to “very important” and “realistic” to “very realistic” to learn during hospitalization. The overall trend was that patients perceived all topics to be more important and realistic to learn during hospitalization than the nurses did. The findings of this study do not wholly support the consensus opinion of the panel who formulated the AHCPR guideline for the treatment of HF caused by LVSD. The AHCPR panel explicitly stated that diet and medications teaching should be conducted before hospital discharge.1 The patient participants, presumably based on their lived experience of having HF, ranked medications as the most important topic, whereas the nurses ranked it second after signs and symptoms. Patients ranked signs and symptoms second and placed diet information as eighth, whereas the nurses ranked diet third. Thus, in both groups, signs and symptoms were ranked higher than the diet information. In comparison with the AHCPR recommendations, this group of nurses would ascribe education of signs and symptoms, medications, and diet as the 3 most important and realistic areas to learn during hospitalization. Patients also indicated a need for information on signs and symptoms. This study thus suggests the addition of a third category of essential content related to signs and symp-
HEART & LUNG
VOL. 28, NO. 1
Learning needs of patients with HF
toms during hospitalization. To improve health outcomes and decrease the necessity for hospitalization, it is essential that patients be able to monitor their own symptoms to ensure early intervention for exacerbations. The greatest risk for rehospitalization for HF is during the immediate postdischarge period.18 Providing patients with the knowledge of signs and symptoms before discharge will allow important self-care monitoring between follow-up appointments. The patients ranked diet education as the last category in both importance and realism to learn during hospitalization. The nurses, however, placed the diet subscale as third in importance behind signs and symptoms and medications in both importance and realism. This demonstrates that nurses who have experience caring for patients with HF caused by LVSD recognize the importance of the diet in the management of HF and as such would prioritize it as an ascribed learning need. Patients placed less importance and realism on the dietary content. This may be a reflection that dietary habits are deeply ingrained and patients may be less interested in changing a lifetime of eating habits. Diet may not be recognized by patients as an important component in managing HF. Specifically, patients may not fully appreciate the relationship of sodium intake with fluid retention. Therefore, patients may not recognize the importance of daily weights in detecting fluid retention before the development of clinical symptoms. The literature suggests that noncompliance with a low-sodium diet is often associated with HF exacerbations.18 Even though diet was ranked lowest by patients, the scores indicated that patients still perceived that this information was “moderately important” and “moderately realistic” to learn during hospitalization. The study findings support the premise that patient education is a vital component of nursing care during hospitalization. As hospitalizations continue to shorten, nurses will be challenged to continue to meet their patient’s educational needs. Nurses need to be aware that, although they may perceive that patient education items are less realistic to learn, patients are eager to master content and believe that it is realistic to learn during hospitalization. Perhaps nurses do a disservice to patients by postponing educational content based on the assumption that it is not realistic for patients to learn. Although learning barriers are present during hospitalization, this study supports the notion that hospitalization may be a motivator and oppor-
39
Learning needs of patients with HF
tunity for obtaining necessary information regarding one’s disease. The findings of this study provide the basis for the development of a comprehensive educational plan for patients with HF. This plan should provide education with use of a variety of media including video, printed materials, discussions, and opportunities to demonstrate self-care management skills. The 8 subscales of the HFLNI are useful for the nurse as a method to compartmentalize the large amount of content into manageable sections. The use of a critical pathway or a similar tool incorporating these topics and individual items contained on the HFLNI could allow for an educational continuum to be developed that transcends hospital- and community-based care. Overall, the nurses and patients were in disagreement on 11 of the 16 subscales, thus indicating an imbalance between the perceived and ascribed needs for the HF population relative to the degree of perceived importance and realism. Nurses must attempt to strike a balance between the perceived needs of the patient and ascribed needs based on the recommendations of the AHCPR. As hospitalizations continue to shorten, nurses across the care continuum will be able to use this information to set priorities for patient education. The educational plan could be implemented at the time of diagnosis, regardless of the setting. Educational objectives can be developed so that the nurse will be able to ensure that a baseline knowledge of HF selfcare management skills have been learned before discharge. When a patient is discharged without mastering the essential knowledge and skills, a plan must be established for acquiring the information in the community setting. For all patients, a seamless health care delivery model would be ideal, because education needs frequent reenforcement to have an impact on behavioral choices and to result in enduring behavioral changes.
40
Wehby and Brenner
REFERENCES 1. Konstam M, Dracup K, Baker D, et al. Clinical Practice Guideline No 11: Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Rockville (MD): Agency for Health Care Policy and Research, Public Health Services, US Depart of Health and Human Services; 1994. AHCPR Publication No: 94-0612. 2. Quall S. Cardiovascular nursing: holistic practice. St. Louis: Mosby–Yearbook; 1992. 3. Lorenz R, Pichert J, Schlundt D, Boswell E. Teaching training for health professionals: effects on immediate recall by surgery patients. Teach Learn Med 1989;1:26-30. 4. Bubela N, Galloway S, McCay E, McKibbon A, Pringled D, Ros E, et al. The patient learning needs scale: reliability and validity. J Adv Nurs 1990;15:1181-7. 5. Grady K, Buckley D, Cisar N, Fink N, Ryan S. Patient perception of cardiovascular surgical patient education. Heart Lung 1988;17:349-54. 6. Kegel L. Advanced practice nurses can refine the management of heart failure. Clin Nurse Spec 1995;9:76-81. 7. Lorenz R. Teaching skills of health professionals. Diabetes Educ 1989;15:149-52. 8. Retchin S, Brown B. Elderly patients with congestive heart failure under prepaid care. Am J Med 1991;90:236-42. 9. Rifas E, Morris R, Grandy R. Innovative approach to patient education. Nurs Outlook 1994;42:214-6. 10. Chan V. Content areas for cardiac teaching: patients’ perceptions of the importance of teaching content after myocardial infarction. J Adv Nurs 1990;15:1139-45. 11. Gerard P, Peterson L. Learning needs of cardiac patients. Cardiovasc Nurs 1984;20:7-11. 12. Karlik B, Yarcheski A. Learning needs of cardiac patients: a partial replication study. Heart Lung 1987;16:544-51. 13. Karlik B, Yarcheski A, Braun J, Wu M. Learning needs of patients with angina: an extension study. J Cardiovasc Nurs 1990; 4:70-82. 14. Wingate S. Post-MI patients’ perception of their learning needs. DCCN 1990;9:112-8. 15. Hagenhoff B, Feutz C, Conn V, Sagehorn K, Moranville-Hunziker M. Patient education needs as reported by congestive heart failure patients and their nurses. J Adv Nurs 1994;19:68590. 16. Knowles M. The adult learner: a neglected species. 2nd ed. Houston: Gulf Publishing; 1978. 17. Knowles M. Introduction: the art and science of helping adults learn. In: Knowles M & Associates, editors. Andragogy in action: applying modern principles of adult learning. San Francisco: Jossey-Bass; 1984.p.1-22. 18. Vinson J, Rich M, Sperry J, et al. Early readmissions of elderly patients with congestive heart failure. J Am Geriatr Soc 1990;38:1290-95.
JANUARY/FEBRUARY 1999
HEART & LUNG