Warfarin patient education: Are we neglecting the program design process?

Patient Education

and Cozcnseling, 14 (19891159- 169 Els$vier Scientific Publishers Ireland Ltd.

Management Rounds

Warfarin Patient Education: Are We Neglecting The Program Design Process? M. Anne Wyness Schoolof Nursing,

University

of British

Columbia, T. 206-2211 V6T 2B5 (Canada,

Wesbrook Mall, Vancouver, B.C.,

(Received November 3rd, 19881 (Accepted May lOth, 19891

Patient education is an important part of safe, effective warfarin therapy. A review of warfarin patient education programs described in the periodical literature over the past 20 years was undertaken. Fifteen relevant articles published between 1972 and 1988 were identified. Most of the articles describe content to be taught. Elements of program design receive limited attention. Patient input into program design is not considered. The literature review clearly demonstrates that principles of program design and outcome evaluation should be applied further by health professionals involved in warfarin patient education. Key words: warfarin; program planning; patient involvement.

Introduction The design of educational programs must be systematic to achieve efficient, quality patient education that helps individuals acquire new knowledge, change behavior and cope with prescribed therapy [l]. Planned programs that clearly define long-range outcomes, behavioral objectives and program inputs in relation to each other reduce the risks of straying into ritualistic or questionable patient education practices [2]. These carefully designed programs are more likely to receive strong administrative support because the rationale and potential benefits are clear [3]. The basic elements of program design include assessment of learning needs, definition of goals, selection of appropriate content and methods, effective implementation, and evaluation [4-61. The most comprehensive model for patient education planning is the PRECEDE framework [2]. This framework 07333991/89/$03.50 0 1989 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland

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recognizes the complexity of behavior change and emphasizes a diagnostic approach. Specific behavioral outcomes are identified and both learner and environmental factors are considered in the design of educational interventions. Evaluation is an integral part of the framework. While the PRECEDE framework is the best available for the design of educational programs, protocols and teaching plans, it is not used consistently. Planned educational programs are a necessary part of safe, effective therapy for patients who take warfarin, an oral anticoagulant. This medication is used in the treatment of conditions such as venous thromboembolism and valvular heart disease. Prevention and treatment of thromboembolism is important because “clinically thromboembolic obstruction . . . contributes materially to early death in our society” [7]. Several factors influence planning for warfarin patient education. The programs are designed for a diverse group of patients whose therapy may be prescribed for a relatively short period of 3-6 months or for life. Because the risk of bleeding is substantial [8], the educational program must be planned to ensure that patients understand the potential for bleeding without experiencing undue anxiety and are not fearful about undertaking usual daily activities. Essential information about regular prothrombin time monitoring and factors that influence the therapeutic effect of warfarin needs to be presented positively and specifically to promote acceptance of responsibility in these areas and behavior change if required. Usually, patients first participate in warfarin patient education programs in hospital when learning is influenced by many factors including anxiety, surgical therapy, pain and fatigue. Incorporating written guidelines for warfarin therapy into the program design is one way to reinforce teaching. In addition, the written information may be useful to patients when questions or concerns arise after discharge from hospital. Because systematic program planning is essential to warfarin patient education, a review of the literature was carried out focussing on program design. Evaluation was also considered. The outcomes of this review are presented and implications for future program planning are discussed. Literature

review

A Medline computer search of the periodical literature from 1966 to 1988 was carried out. The key words used were patient education, patient teaching, oral anticoagulants, warfarin and Coumadin e. Fifteen relevant articles were obtained for the period 1972- 1988. An additional eight articles noted the importance of patient education in warfarin therapy and outlined key points to include either in the context of anticoagulant therapy in general [9 - 121 or specific disease conditions [13,14]. The major focus of these articles was not on patient education and therefore, they were not included in the analysis. No articles were retrieved for the 1966 to 1971 period. The articles were classified according to two main topics: program design and evaluation. Ten articles discussed program design aspects, one focussed equally on anticoagulant therapy and components of program design, and four were directly related to elements of evaluation. 160

The components examined for each article were: health profession(s) of the author(s), assessment of learning needs, patient involvement in program design, content outline, teaching materials, documentation of patient education and evaluation of outcomes. The results of this analysis are outlined in Table I. Patient involvement in program design was never discussed and therefore, is not included in the summary. Results The results categories.

of the

analysis

are

presented

using

the

two

main

topic

Program design Eleven articles between 1976 and 1988 described, with varying specificity, elements of programs designed for patients taking oral anticoagulants. The majority of authors were nurses or pharmacists. Assessment of learning needs was discussed in five articles. In the program described by &alley et al. [17], learning needs were assessed and documented using content-focussed objectives. The importance of assessment was noted in two [18,19] while one [20] discussed assessment indirectly. Wiser and Mintzer [21] followed up teaching at an initial clinic visit by assessing knowledge at subsequent visits. Objectives were stated in behavioral terms in one article [17]. General goals were outlined by Hickman et al. [20]. The importance of establishing objectives was pointed out in a third article [19]. Content was the element that received the most emphasis. Warfarin patient education programs should include content related to taking warfarin accurately and safely, measurement of prothrombin time, actions to prevent bleeding or thrombosis, what to do if significant bleeding or bruising occurs, effects of dietary vitamin K, alcohol, and drug interactions, particularly acetylsalicylic acid, on the action of warfarin and information basic to the warfarin regimen such as frequency of laboratory visits. Eight articles [17 - 19,22 - 261 outlined content specifically and discussed at least 900,b of the desired content elements. Problems related to skin necrosis [27] were rarely mentioned. The therapeutic range for prothrombin time was not always congruent with current recommendations in the literature [28]. The points emphasized appeared to be influenced by the individual perspective and judgment of the clinician; for example, recommendations regarding the use of an electric razor and the amount of care to take during activites such as gardening or sewing. Examples of teaching materials were provided in five articles [18,20,21,23,26]. Printed material was used most frequently but two programs included audiovisual aids [17,29]. Several authors noted the need for written reinforcement of verbal teaching [18,20,23]. One program [20] had patients administer their own warfarin after they participated in the education sessions. A nurse was present to assist patients if necessary. Documentation of learning needs and the educational process was rarely 161

5

1291

Reinders, TP Steinke, WE

[311

[231 Rankin. MA

Ewy, GA Ulfers, L Samuels, T

P21

Moore, K Maschak, BJ

WI

Kradjan, WA

[301

1979

1979

1978

1977

1976

Pharmacy Medicine

Nursing

Program design and evaluation

Evaluation

Program design

Program design

Nursing

Medicine Nursing One unstated

Program design

Evaluation

Pharmacy

Nursing

1972

Clark, CM Bayley, EW

Not

Not discussed

Not discussed

Not discussed

Noted as important

Not discussed

Not stated

Not stated

Not stated

Not stated

Not stated

Stated as terminal bebehaviors

Objectives

REVIEW

Assessment of learning needs

LITERATURE

Category

EDUCATION

Health profession(s)

PATIENT

Date of publication

OF WARFARIN

Author&l

SUMMARY

TABLE I

Not specifically described

Described specifically Discussed specifically in manual Briefly outlined

Described specifically

Briefly outlined

Content outline

Programmed instruction booklet Leaflet Information brochure Self-instruction text Audiovisual program

Manual included

Programmed instruction booklet Printed information sheet Examples of patient instruction sheet and patient teaching card Booklet

Teaching materials

Not discussed

Not

Not discussed

Not discussed

Not

Experimental and control

Not discussed

tion use

Two groups of subjects post-test design No formal plan presented States patients increased knowledge of safelappropriate medica-

Not discussed

Not discussed

groups Post-test design No formal plan presented

Evaluation of outcomes

Documentation

1351

Witte, K Gurwich, EL Anzalone, R Campagna, MA

1211

Wiser, TH Mintzer, DL

PO1

Hickman, K Tortorici, MP Knight, JL

[171

Scalley, RD Kearney, E Jakobs, E

1980

1980

1980

1979

Pharmacy

Pharmacy

Pharmacy

Pharmacy nursing

Evaluation

Program design

Program design and evaluation

Program design

Not discussed re initial teaching Knowledge assessed at second clinic visit Not discussed

Discussed indirectly

Assessment based on specific objectives

Leaflet on warfarin Dosage calendar Wallet identification card Application for Medic Alert bracelet Patient education sheet Pocket calendar

Booklet Diagrams

Described in general terms

Topic areas outlined

Key points discussed

General goals stated

Not stated

Indicates were written for program Audit criteria stated based on objectives

Film Booklet Wallet identification card

Described in objectives Film topics

Stated specifically

Not discussed

Not discussed

Checklist of learning objectives used to document needs Teaching documented in relation to each objective Teaching documented on chart and on patient’s medication record in pharmacy

Pre- and posttests used to evaluate knowledge 20 patients rated 100%

Patient questionnaire sent 2 months post discharge 34 of 59 patients responded 33 stated was beneficial No formal plan presented Informal assessment at each visit

Improved compliance with therapy suggested by periodic data review Not discussed

1982

1985

Thompson, DA ~41

Bulman,T 1331

WI

1981

Maschak-Carey,BJ Moore, K

Nursing

Nursing

Nursing

Date of Health publication profession(s)

Authors(s)

TABLE I (continzced)

Not discussed

Noted as important

Assessment of learning needs

Evaluation Not discussed

Program design and anticoagulant therapy Program design

Category

Stated as standards Expected outcomes expressed in behavioral terms

Not stated

Noted it is important to establish objectives

Objectives

Specific content outlined

Described specifically

Outlined specifically

Content outline

Noted as important

Documentation

Not discussed

Patient teaching record using objectives

Pocket calendar Not discussed

Not discussed

Teaching materials

No formal plan presented States hospital admissions for bleeding and clotting complications decreased dramatically since intensive client education program begun No formal plan Example of audit tool provided

after program Number of patients knowledgeable about each criterion increased Noted important as an ongoing process

Evaluation of outcomes

WI

1251 Swithers, CM

Hospital Pharmacy Department

1988

1987

Nursing

Pharmacy

Program design

Program design

Not discussed

Not discussed

Not stated

Not stated

Outlined specifically

Specifically discussed Patient instruction sheet included

Not discussed

Not discussed

Not discussed

Not discussed

Not discussed

discussed. Two articles [17,20] provided tion systems.

specific information

about documenta-

Evaluation Formal evaluation of learning outcomes was rarely part of the design of any of the educational programs. Hickman et al. [20] used a patient questionnaire to determine perceptions of program benefits. The questionnaire was sent to all patients 2 months after discharge. Thirty-four of 59 questionnaires were returned. Of the 34 patients, 33 reported the program was beneficial. Reinders and Steinke [29] did not describe their evaluation methods but noted patients demonstrated increased knowledge concerning safe and appropriate use of their medication. In addition, they stated periodic data review suggested improved compliance with therapy. Thompson [24] also did not provide information about evaluation methods but noted hospital admissions for bleeding and clotting complications decreased dramatically following institution of an intensive patient education program. Two research studies [30,31] focussed on the content and teaching material elements of program design by evaluating the effectiveness of programmed instruction. Clark and Bayley [30] found hospitalized patients who participated in programmed instruction scored significantly higher on an objective test than patients who read an information sheet or received no structured teaching. Rankin [31], using the programmed instruction material developed by Clark and Bayley, reported patients scored higher on a knowledge test at 3-4 days and 3 weeks after reading the material than patients who read an American Heart Association leaflet on warfarin. Of interest is the finding that the mean score at 3 weeks for the programmed instruction group decreased while that of the leaflet group increased. In the field of patient education, evaluation in the context of quality assurance is receiving increasing attention [32 - 341. Two articles discussed warfarin patient education in relation to quality assurance [35,36]. Witte et al. [35] set clear audit criteria and used a pre-test, post-test design to evaluate achievement of the criteria. While the number of patients knowledgeable about each criterion increased, the audit results indicated that the teaching time needed to be augmented to make the program more effective. Standards of care for anticoagulant therapy were used by Bulman [36] to describe one approach used to assure safe care for patients at a large ambulatory care centre. All the program design elements except assessment and teaching materials were well developed. The standards were clear and specific. A teaching record that included behavioral objectives and content guidelines for nurses using the record was presented. The audit tool was clearly described but no audit results were provided. Other Several articles provided useful information related to the design of warfarin patient education programs. Erdman et al. [37] described a successful approach to long term oral anticoagulant therapy that involved patients in the

166

determination of the amount of medication to take. No information was given about patient education methods. Hoffer et al. [38] developed a computerized system to predict anticoagulant dose based on prothrombin time. Although education was not a focus, patients were mailed instructions about the dose to take and the date of the next prothrombin time test. The authors stated patients who received the written instructions more frequently took the correct dose than patients who received the same information by telephone. A study [39] examining compliance in patients with prosthetic heart valves taking anticoagulants, diuretics and cardiac medications found compliance highest for anticoagulants. The authors proposed that requirement of monthly visits for prothrombin time tests enhanced compliance with anticoagulant therapy. Implications for future program design Descriptions of warfarin patient education programs illustrate inconsistent application of health education principles. Based on the literature reviewed, the major emphasis has been on developing content. Limited attention has been given to devising tools for assessment of learning needs, stating behavioral objectives, developing documentation systems, and designing approaches to evaluate learning outcomes. Teaching materials, particularly printed ones, have been created to present content and reinforce verbal presentations. Further consideration should be given to elements other than content if warfarin patient education is to be effective. Mechanisms to ensure programs are appropriate for the intended audience need to receive particular attention. Formative evaluation, for example, by pretesting [40], should be an integral part of program planning. Patient input into program design was not discussed in any of the articles. To be successful, educational programs must be effective from the patient’s viewpoint not just from the health professional’s viewpoint. Active involvement of patients helps identify learning needs, promotes participation in the educational program and may help achieve greater cooperation with required changes in habits or lifestyle [4,41,42]. Pretesting of printed materials is a valuable area for patient input. One approach is to ask patients to be “copy-editors”. This technique was used by the author in the development of a booklet that is part of a warfarin patient education program. The copy-editing instructions were adapted from an evaluation instrument designed by Cox and Wentworth [41]. Health professionals responded positively to the patient input obtained by copy-editing because specific, new data were available that was useful in program planning. The technique is a valuable one that could be used in a variety of settings. It does require patients with at least average reading ability who are willing to be critical. In addition, copy-editing has excellent potential as a method for assessing learning needs. To achieve comprehensive, quality programs, a structured, systematic

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approach to planning should be used. The PRECEDE framework offers potential in this area. In addition, the design of methods to evaluate learning outcomes is important so that results of evaluation research can be used to refine programs. The contribution of warfarin patient education programs to safe, effective therapy will continue to be based on opinions without careful planning and evaluation. Conclusions Review of the warfarin patient education literature clearly demonstrates that program design and evaluation need to be considered further. The content of programs has been emphasized, with limited discussion of other elements. Strategies such as copy-editing and other methods of patient participation should be included in future warfarin patient education program design. The theoretical base for education about warfarin, a medication with the potential for significant complications, needs to be strengthened. References 1 2 3 4 5 6 ‘7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

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