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Knowledge and skills needed for patient education for individuals with

coronary heart disease: The perspective of health professionals

Article  in  European Journal of Cardiovascular Nursing · September 2014

DOI: 10.1177/1474515114551123 · Source: PubMed

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Some of the authors of this publication are also working on these related projects:

Competence in patient education View project

Lifestyles, risk factor management and self-care of individuals with coronary heart disease (The KRANS-study) View project

Margret Hronn Svavarsdottir

University of Akureyri

17 PUBLICATIONS   71 CITATIONS   

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Arun K Sigurdardottir

University of Akureyri

42 PUBLICATIONS   472 CITATIONS   

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Aslak Steinsbekk

Norwegian University of Science and Technology

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European Journal of Cardiovascular Nursing 2016, Vol. 15(1) 55 –63 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515114551123 cnu.sagepub.com

E U R O P E A N SOCIETY OF CARDIOLOGY ®

Introduction

Coronary heart disease (CHD) is the leading cause of death and disability in Europe.1 Unhealthy lifestyle is causative in this disease, and the benefits of decreasing the risk factors are great.2,3 Although evidence clearly shows the beneficial effect of lifestyle changes, main- taining a healthy lifestyle is a challenge for even the most dedicated patient.4,5 Patient education is an impor- tant element in secondary prevention of CHD, as educa- tion has been reported to increase knowledge and the likelihood of successful lifestyle changes6 and may increase health-related quality of life.7 Patient education relates to a combination of learning experiences that

influence behaviour change and produce changes in the knowledge, attitudes and skills needed to maintain and improve health.8

Knowledge and skills needed for patient education for individuals with coronary heart disease: The perspective of health professionals

Margrét H Svavarsdóttir1,2, Árún K Sigurðardóttir2 and Aslak Steinsbekk1

Abstract Background: There is a lack of studies on the knowledge and skills needed for patient education of individuals with coronary heart disease. Better understanding of what competencies health professionals see as necessary for patient education in secondary prevention can contribute to improved education of educators, and thus, improved patient education. Aim: The purpose of this study was to investigate health professionals’ views on the knowledge and skills necessary in conducting high-quality patient education for adults recently diagnosed with coronary heart disease. Methods: A qualitative study was conducted using individual interviews with health professionals with experience from different types of patient education in cardiac care. The interviews were analysed using systematic text condensation. Results: The informants were 19 Icelandic and Norwegian registered nurses, physiotherapists and cardiologists. Sound updated theoretical and clinical knowledge, along with advanced communication skills, was considered essential for patient education. This includes being able to establish interpersonal relationships with patients, capturing their learning needs, facilitating an effective dialogue and providing individualised patient centred education and lifestyle counselling. Conclusions: Evidence-based patient education requires knowledgeable health professionals with advanced communication skills and pedagogical competences that enable them to motivate patients and provide effective patient centred lifestyle counselling.

Keywords Patient education as topic, clinical competence, health personnel, health educators, coronary disease, secondary prevention

Date received: 1 April 2014; revised: 20 August 2014; accepted: 22 August 2014

1 Department of Public Health and General Practice, St Olavs University Hospital, Norwegian University of Science and Technology (NTNU), Trondheim, Norway

2School of Health Sciences, University of Akureyri, Iceland

Corresponding author: Margrét H Svavarsdóttir, Department of Public Health and General Practice, NTNU, Postbox 8905 MTFS, 7491 Trondheim, Norway. Email: [email protected]; [email protected]

551123CNU0010.1177/1474515114551123European Journal of Cardiovascular NursingSvavarsdóttir et al. research-article2014

Original Article

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56 European Journal of Cardiovascular Nursing 15(1)

Despite recognition of the importance of patient educa- tion, several studies indicate that it is frequently neglected,9–11 is sometimes ineffective10,12,13 and does not always correspond to patient needs.14–16 In addition, patient knowledge of CHD10,12,14 and adherence to recommended treatment are often inadequate.17,18

Health professionals consider knowledge in educa- tional science important for patient education.19 In spite of this and the increasing emphasis on evidence-based prac- tice,20,21 inactivity in reading literature related to patient education and following knowledge development in those areas has been reported.19 Lack of competences22–25 and inadequate training of health professionals have been iden- tified as barriers in patient education,9,25,26 and the need for continuing education for patient educators has been acknowledged.9,26

There is a lack of research addressing what knowledge and skills educators of patients with CHD should have. A recent study revealed that patients believe that health pro- fessionals in cardiac care must be knowledgeable, skilful and able to meet the educational needs of patients and families.27 However, it is not known what attributes are required according to health professionals themselves. Exploring the views of those who are motivated and active in patient education enables reflection of the competencies that experienced educators use in their daily clinical prac- tice and the challenges they faced as novice educators. Opinions of health professionals with experience in car- diac care can give indications about the knowledge and skills needed to reach competency in patient education. The aim of this study was to investigate what health pro- fessionals perceive as necessary knowledge and skills to perform high-quality patient education for adults recently diagnosed with CHD.

Methods

In this qualitative study, semi-structured in-depth individ- ual interviews were used. The design was chosen since it is well suited for exploring the range, depth and complexity of people’s perspectives when little is known about the subject area.28

Sample and recruitment

The aim was to use purposeful sampling to recruit health professionals with experience in providing patient education (e.g. formal education, individual and group education, information giving, support and lifestyle coun- selling) to individuals with CHD. There were no exclusion criteria. The first author introduced the study in cardiac care units and enrolled volunteers. The volunteers were then asked to recommend others (snowball sampling). To ensure variation in the sample, registered nurses, physio- therapists and cardiologists in Norway and Iceland were invited to participate. Informants were selected according

to variation in age, gender, profession, work experience and experience with patient education.

Data collection

Data collection took place between April–August 2013. The first author conducted all the interviews at a place chosen by the informants. The interviews were audiotaped and transcribed verbatim. The average interview duration was 40 min (range 23–64 min).

In this study, patient education was defined for the informants as a comprehensive term, to cover all formal patient education, information giving, support and lifestyle counselling given to patients by health professionals in the first year following the diagnosis of CHD. A semi- structured interview guide was used. Initially, the inform- ants were asked to explain what they considered optimal training in patient education for inexperienced educators who provide education for adults recently diagnosed with CHD (i.e. who had survived first-time myocardial infarction or undergone first-time elective percutaneous coronary intervention). Other main questions were as follows: What knowledge and skills are needed to conduct high-quality patient education? What are the main challenges health pro- fessionals encounter in education for individuals with CHD?

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki. The informants received informa- tion, both orally and in writing. This included information about the possibility of withdrawing from the study at any time. Written consent was obtained before the interviews were conducted, and confidentiality was assured.

Analysis

The data were analysed using systematic text condensation described by Malterud.29 Examples are shown in Table 1.

An iterative four-step process was conducted, starting after the first interview, by reading the transcribed inter- views to obtain a general impression and identify prelimi- nary themes. In the second step, the transcriptions were systematically reviewed line by line and the units of mean- ing identified, classified and sorted into themes. The third step was to sort the units of meaning into subgroups and reduce the content to a condensate of artificial quotations, maintaining as far as possible the original terminology used by the participants. In the last step, the contents of each code group were summarised into generalised descriptions and concepts.

The analysis was performed by the first author and dis- cussed and negotiated with the co-authors and a team of experienced researchers. Coding of the interviews contin- ued after each interview until no new themes emerged. At that point, the material was considered saturated. The

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Svavarsdóttir et al. 57

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58 European Journal of Cardiovascular Nursing 15(1)

analysis was validated with a thorough review of the orig- inal transcripts of each interview to make sure they were reflected in the results. Citations used to support the results are marked with the informant’s profession and self- evaluated experience with patient education.

Results

The sample consisted of 19 Icelandic and Norwegian health professionals (Table 2). Their mean age was 42 years (range 25–62 years), and the mean length of clinical experience in cardiac care was 12 years (range 0–32 years). All of the informants, except one, had some formal educa- tion in patient education. All had experience with in- hospital patient education and 18 had experience in patient education after discharge from hospital. Six had experi- ence with counselling in nurse-led clinics. Five nurses were specialised in cardiology and one physiotherapist in cardiopulmonary rehabilitation.

The health professionals’ views are presented according to three themes. Most began the interview by explaining the necessity of having good professional knowledge from

theoretical literature and clinical experience. This is described in the themes theoretical knowledge and clinical knowledge. In addition, there was a clear focus on advanced communication skills. Figure 1 shows a summary of the results and the interaction of knowledge and skills needed in high-quality patient education.

Theoretical knowledge

Sound updated medical knowledge about cardiac disease was seen as a basic competency in patient education by all informants. Some considered it the most important knowl- edge. An experienced cardiologist said:

‘The point is that after all, professional knowledge becomes more important than the capability to teach’.

Others expressed the view that despite the weight of medical knowledge, its relevance will be attenuated in the absence of effective communication skills and the capabil- ity to connect to people.

Many informants emphasised that in order to be able to understand and help patients to cope with disease, educa- tors must gain knowledge about patients’ experience, con- cerns and emotional reactions. Some informants said that educators must have knowledge of what patients are likely to ask about and what is relevant at each stage in the dis- ease continuum. One cardiologist stated that all patients have key questions that are not necessarily asked but must be addressed by health professionals.

It was stressed that health professionals must know how to acquire new knowledge and be up to date in evi- dence-based medicine. In addition, some nurses argued that in order to correct misinformation and facilitate dis- cussions, knowledge about contemporary topics under discussion in society is needed. This could also be helpful in guiding patients in choosing treatments and increasing the credibility of health professionals. An experienced nurse stated:

“There are more young individuals who are well-read on the Internet. You need to follow up on that information, and that is a challenge and time-consuming… But they can be well read in something that is complete nonsense… Somehow, you need to correct those ideas.”

Some nurses and physiotherapists believed that an edu- cator should possess interdisciplinary medical knowledge and knowledge about educational topics presented by other health professional disciplines. It was suggested that this knowledge could increase the educators’ capability to respond to questions, provide explanations and ensure congruence. The need for knowledge in educational sci- ence and adult learning was raised by many. However, some informants implied that educating and counselling relied on experience or innate skills.

Table 2. Demographic characteristics of the informants.

Number

Gender Female 17 Male 2 Nationality Norwegian 11 Icelandic 8 Profession Registered nurse 14 Physiotherapist 3 Cardiologist 2 Highest academic degree BSc 13 MSc 4 PhD 2 Source of competence in patient education Self-study (e.g. books/literature) 17 Supervision from experienced colleague 14 Undergraduate education 12 Postgraduate education 12 Course in patient education 7 Experience in patient education >3 years 14 1–3 years 3 <1 year 2 Self-evaluated experience in patient education

Little experience 0 Average experience 3 Experienced 13 Extensive experience 3

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Svavarsdóttir et al. 59

Clinical knowledge

It was frequently mentioned that clinical experience results in the type of clinical knowledge necessary for patient education. However, some argued that clinical experience does not necessarily result in competency in patient education, if there was no interest in or dedication to the subject.

A more experienced educator was considered better able to read signals, for example, facial expressions and non-verbal communication, and capture emotional and learning needs. The informants stated that confidence to leave predefined topics and let patients concerns and inter- ests lead the education depended on clinical experience. A nurse with average experience said:

‘You can probably conduct acceptable patient education after a couple of years [in clinical] work. You could have good theoretical knowledge; however, you might not have that much experience with patients yet. There are so many variations, individual differences, which I think you will learn to recognise over time.’

Advanced communication skills

Advanced communication skills included being able to establish interpersonal relationships with patients, capture their learning needs and readiness to learn, facilitate an effective dialogue and provide individualised guidance and lifestyle counselling.

The ability to establish interpersonal relationships and build trust was identified as the foundation for effective

communication and patient education. This included being caring and able to empathise and having genuine interest in the patient. By relating and connecting to the patient, the educator was said to be more competent in supporting him or her through illness and recovery. An experienced nurse stated:

‘That you are able to help them gain control over their body and their health. Create trust and maybe create some hope that life can be the same as before’.

One cardiologist talked about the need for being modest in behaviour while meeting with patients and creating a sense of equality in the relationship. Another important aspect of interpersonal relationships was said to be a non- judgmental attitude and respect for patient wishes, needs and decisions. An experienced nurse stated: ‘To meet him where he is, but at the same time ensure that he does not endanger his health’. Another experienced nurse recommended that:

‘It is more effective to have a conversation with the patient instead of lecturing, or telling him what to do… Involve the patient in the education’.

The ability to create a climate that promotes learning and makes patients feel comfortable asking questions and discussing sensitive topics was emphasised. This implies that the educator also must be comfortable discussing sen- sitive issues without embarrassing the patient.

The ability to capture patients’ learning needs and readi- ness to learn was considered an essential skill for an educa- tor. One concrete example was to understand the patients’ learning needs and the need to evaluate the patients’ prior

Figure 1. Interaction of knowledge and skills in patient education.

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60 European Journal of Cardiovascular Nursing 15(1)

knowledge, interest and motivation. This was required in order to be able to individualise and prioritise the informa- tion to be given. An experienced cardiologist stated:

‘The education must focus on the patient’s reality, which becomes important for the patient in making lifestyle changes and to follow medical treatment’.

Some of the more experienced informants considered it very important to be skilled in exploring and recognising barriers and facilitators of learning. An experienced nurse explained it this way:

‘To be able to assess what the obstacles for change are for this individual. … To be able and have patience and motivation to go deeper into those issues and find something that you can work with’.

The informants favoured patient-centred education and two-way communication between educators and patients. This included skills in starting and leading discussions, engaging passive patients and controlling storytelling and dominant patients.

The informants emphasised that educators should be able to adjust discussions and information to patients’ level of understanding. One example offered was being able to disseminate information and give understandable instruc- tions using lay terms and speaking clearly and concisely.

To communicate relevant knowledge at a relevant time in a way that motivates learning and a healthier lifestyle was often considered the biggest challenge to patient edu- cation. Some informants also mentioned difficulties in supporting patients in maintaining lifestyle changes. The focus on lifestyle counselling was especially apparent among the more experienced informants, in particular those with experience from nurse-led clinics.

Discussion

Our main finding was that health professionals who were experienced in patient education considered sound theo- retical and clinical knowledge essential for patient educa- tion, along with advanced communication skills. This included being able to establish interpersonal relationships with patients, capture their learning needs, facilitate an effective dialogue and provide individualised guidance and lifestyle counselling.

Experience or evidence-based patient education?

Despite the emphasis on evidence-based medicine, there seems to be a strong belief in learning by doing and consult- ing colleagues,30 which some of our informants highly appreciated as a method of seeking knowledge. Research indicates that patient education is performed in an

unarticulated and unreflective way.19 Even though health professionals consider knowledge in educational science important in patient education,19 it has been stated that its value is underestimated22 and some believe giving informa- tion and communicating are natural abilities.31 Although some of our informants stressed the importance of formal training in communication and educational science, others questioned this idea and implied this to be innate skills that relied on experience. This is an uneasy position that needs to be addressed. To ensure high-quality patient education, the importance of pedagogical knowledge and evidence-based patient education must be recognised and used by health pro- fessionals. Health professionals might refrain from evidence- based praxis as a result of socialisation and the demand for efficiency.32 An important question is whether health profes- sionals consider it equally important to apply the principles of evidence-based practice in patient education as in clinical health care. Poor outcomes in patient education10,13 further raise the need to support health professionals toward peda- gogical competence and evidence-based patient education.

The challenge of communication and motivation

It has been argued that engaging in dialogue with patients and empowering them with education improves adherence to the recommended treatment.33 Consistent with the phi- losophy of empowerment34 and patients’ wishes,27 the informants believed the role of the educator is to be to inspire, inform, support and facilitate patients’ efforts to identify and attain their own goals. The low frequency of adherence to recommended treatment17,18 and mounting evidence of the beneficial effects of lifestyle changes2,3 support the view that educators ought to be well-versed in communication and lifestyle counselling. Furthermore, making lifestyle changes seems to be one of the more dif- ficult tasks patients with CHD face.14 Our informants saw lifestyle counselling as the most challenging task in edu- cating individuals with CHD. This is in line with research in which health professionals have reported that the lack of counselling skills represent a barrier to lifestyle counsel- ling,11,35 indicating that a central competency that needs further training is how to work with lifestyle changes.

Increased emotional well-being has been reported among patients who receive patient-centred education compared to those who receive standardised information.36 Parallels can be drawn between patient-centred educa- tion36 and what our informants felt about the necessity of developing an interpersonal relationship that focused on emotional needs and identifying and respecting values and preferences. However, one can question whether this view reflects the current situation in clinical practice, as our results contradict research that demonstrate that patients find that education places too much weight on the disease15 and too little on psychological well-being.16

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Svavarsdóttir et al. 61

In accordance with prior research,37 our informants considered it important that health professionals were capable of creating a climate that promotes learning and makes patients feel comfortable asking questions and expressing themselves. Shared authority and group owner- ship have been described as central for educators in diabe- tes care.37 This is in line with the view of our informants that patients should be seen as active partners and their concerns and interest should steer the education. Suggestions from the informants about the beneficial effect of creating a sense of equality in the relationship with the patient are supported by results of a qualitative study in which cardiac patients reported that they felt more relaxed and able to confide and discuss issues freely when they felt on the same level as the health professional.38 Patient-centred communication is an important core com- petency in patient education that health professionals require education and training in if they wish to develop as effective educators.

Strengths and limitations

The main strength of this study was that it included the three health professions most involved in patient education for individuals with CHD. The majority of the informants were registered nurses, which reflects clinical situations well since the most frequent educators of individuals with CHD are nurses and health professionals in multidisciplinary teams.6 To further increase the variation in the sample, informants in two countries and in various patient care set- tings were included. Another important strength lies in the great experience the majority of the informants had in patient education in cardiac care. Some also had experience in training health professionals in patient education. Since we intentionally recruited health professionals with experi- ence from patient education, the sample is likely to be repre- sentative only of those experienced and engaged in the field. This means that our findings do not reflect the perspective of all health professionals, particularly those with no experi- ence in patient education, although with a bias toward male health professionals, since only two men agreed to partici- pate in the study.

The major limitation of the study was that the results were based on the views and professional opinions of health professionals, rather than actually testing which competencies are most relevant in clinical practice. This approach was conscientiously chosen due to the absence of comprehensive descriptions of knowledge and skills needed for patient education of individuals with CHD.

The first author had experience in patient education related to individuals with CHD. To avoid preconceptions affecting the reflexivity of the results, the interview guide and the interpretation of the interviews were critically dis- cussed with the co-authors and in a team of experienced researchers. In addition, the co-authors reviewed the orig- inal transcripts of the interviews in their respective

languages to make sure the informants views were reflected in the results.

Conclusion

Knowledge and advanced communication skills are inter- related and must be present in high-quality patient educa- tion. Effective training is needed for health professionals to acquire the competencies that enable patients better man- age their CHD. Evidence-based patient education requires knowledgeable health professionals with advanced com- munication skills and pedagogical competence that makes them able to motivate patients and provide effective life- style counselling.

Implications for practice and research

The results describe important competencies to be mas- tered in relation to interdisciplinary patient education to individuals with CHD and can be a useful basis for com- prehensive descriptions of knowledge and skills needed for patient education. Better understanding of what com- petencies are necessary for patient education can contrib- ute to an improved continuing education curriculum for health professionals in patient education, and thus, improved patient education. In addition, the findings can encourage educators of individuals with CHD to critically reflect on their competencies as educators and the knowl- edge, skills and resources they will need in order to develop as expert educators.

Further research is needed to better understand how the identified core competences relate to each other and the various roles of educators, educational settings and the dis- ease continuum. Such research could focus on identifying which competences are most beneficial in different set- tings. This could help uncover how these competencies should be taught in continuing education for health profes- sionals’ since this is likely to be important step to increase the quality of educators.

Implications for practice

•• The results can be a useful basis for comprehen- sive descriptions of knowledge and skills needed for patient education to individuals with CHD.

•• Better understanding of what competencies are necessary for patient education can contribute to improved continuing education curriculum for health professionals in patient education, and thus, improved patient education.

•• The findings can encourage educators of indi- viduals with CHD, to critically reflect on their competencies as educators and the knowledge, skills and resources they will need in order to develop as an expert educator.

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62 European Journal of Cardiovascular Nursing 15(1)

Acknowledgements

The authors wish to thank the health professionals who partici- pated in the study. They also thank the Research Group for Patient Education and Patient Participation, at the Department of Public Health and General Practice, Norwegian University of Science and Technology in Trondheim, Norway for critical dis- cussion and good advice during the process of planning this study and analysing the results.

Conflict of interest

The authors have no conflict of interest.

Funding

This project is funded by Central Norway Regional Health Authority.

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