The European Journal of Heart Failure 7 (2005) 363 – 369 www.elsevier.com/locate/heafai
The crucial role of patient education in heart failure Anna Strfmberg*
Received 18 May 2004; received in revised form 8 December 2004; accepted 4 January 2005
Abstract Background: Deterioration of heart failure causes and complicates many hospital admissions in people aged over 65 years. Frequent readmissions cause an immense burden on the individual, the family and the health care system. Heart failure management programmes, in which patient education is an important component, have been shown to be effective in improving self-care and reducing readmissions. Aim: This paper reviews the literature on the education of patients with heart failure. The paper addresses the level of knowledge in patients with heart failure, barriers to learning, learning needs, educational methods, goals and how the effects of patient education can be evaluated. Conclusion: Many patients had low levels of knowledge and lacked a clear understanding of heart failure and self-care. Educational interventions need to be designed specifically for elderly patients and need to target barriers to learning such as functional and cognitive limitations, misconceptions, low motivation and self-esteem. Health care professionals need to be skilled in assessing the requirements and level of education given to the individual. New technologies such as computer-based education and telemonitoring can be used as tools to improve the education. Patient education is an important component of heart failure care and should be provided through effective and wellevaluated strategies. D 2005 European Society of Cardiology. Published by Elsevier B.V. All rights reserved. Keywords: Heart failure; Patient education; Educational intervention
Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Introduction . . . . . . . . . . . Knowledge on heart failure . . . Barriers to learning . . . . . . . Learning needs . . . . . . . . . Education models . . . . . . . . The process of patient education Educational provider, setting and Educational goals . . . . . . . . Evaluation of patient education . Conclusion . . . . . . . . . . . References . . . . . . . . . . .
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* Department of Cardiology, University Hospital, S-581 85 Linkfping, Sweden. Tel.: +46 13 227762; fax: +46 13 222224. E-mail address:
[email protected]. 1388-9842/$ - see front matter D 2005 European Society of Cardiology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejheart.2005.01.002
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Department of Cardiology, Heart Centre, Linko¨ping University Hospital, Sweden Department of Medicine and Care, Faculty of Health Sciences, Linko¨ping University, Sweden The Va˚rdal Institute, Sweden
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1. Introduction
Table 1 Learning barriers in patients with heart failure, strategies to overcome them and examples of interventions Barriers
Strategies
Interventions
Functional limitations— visual, hearing, mobility
! assessment of limitations ! adapt material and method to limitations
! use teaching aid, e.g., computer programmes with large buttons, text and pictures and a touch screen or booklets with enlarged text
Cognitive limitations— memory problems
! adapt material, methods, teaching pace and number of repetitions ! divide information in small segments ! involve caregiver ! education to spouse or caregivers
! interactive computerbased education ! short, concise booklets ! extensive repetition
Misconceptions and lack of bbasic knowledgeQ
! track misconception and assess knowledge
! use multiple teaching methods and material ! provide basic education
Low motivation and interest
! tailoring ! meaningfulness of the material
! evaluate patient situation and learning needs ! holistic view on patient education, e.g., not only teach about heart failure ! evaluate depression and fatigue
Low self-esteem
! nonthreatening climate ! positive feed-back ! support
! establish confident relationship between patient and health care professionals ! education in combination with social support, e.g., through follow-up at clinic, home visits or telecare
2. Knowledge on heart failure There are only a few studies examining the level of knowledge on heart failure [19–22] and three interview studies exploring the understanding of heart failure [23] and its pharmacological treatment [24,25]. In a study by Ni et al. [20], education was provided through written material to 71% of patients and verbal instruction to 75% of patients, 60% of patients received both types of education. Among the patients that had been educated, 14% stated that they knew a lot about heart failure, 38% knew a little or nothing and the rest knew some. Sneed et al. [22] showed that among heart failure patients that were educated, 39% stated that they knew a lot and 55% stated that they knew something. It seems that even if patients are educated, they do not consider themselves to have comprehensive knowledge about heart failure. Many patients are not aware that they suffer from heart failure. Ekman et al. [26] found that 20% of the patients with moderate to severe heart failure did not know that they had been diagnosed with heart failure. It has also been shown that very few patients could define heart failure [21,22]. Knowledge on how to identify symptoms was high, but still not satisfying [19,27]. Knowledge on self-care has
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Heart failure is the most common reason for admission to hospital in people aged over 65 years and complicates many more admissions [1,2]. Data from various populations suggest that up to 50% of patients hospitalised due to heart failure are readmitted within 6 months [3,4]. Hospitalisation accounts for up to 70% of the total health care costs for heart failure [1,5]. Heart failure is a chronic syndrome with a poor prognosis and deterioration of the disease is not always preventable. However, it has been proposed that up to half of readmissions are preventable. Many of these admissions are caused by the failure of health care providers to target high-risk patients, prescribe optimal treatment, provide discharge planning, education and follow-up. Readmissions can also be caused by the patients’ failure to adhere to medical treatment and diet regimen, inability to perform self-care behaviour, including monitoring symptoms of deterioration and failure to take action in order to prevent further deterioration [6–9]. The implementation of disease management programmes has been shown to be successful in reducing the number of readmissions [10]. Education, often delivered by nurses, is an important part of all management programmes for patients with heart failure, both in clinical practice [11,12] and research [13–18]. This paper reviews the literature on the education of patients with heart failure. The paper addresses the level of knowledge in patients with heart failure, barriers to learning, learning needs, educational methods, goals and how the effects of patient education can be evaluated.
also been shown to be poor; Ni et al. [20] found that 40% of patients did not understand the importance of daily weighing and one-third of patients believed they should drink a lot of fluids. Cline et al. [24] found that half of the patients interviewed knew the names and doses of their prescribed medications. Rogers et al. [25] identified that patients with heart failure had little understanding of the purpose of their medication and on how to interpret and treat symptoms of deterioration and they did not have enough knowledge to be able to differentiate between symptoms and side effects of the drugs. Some differences due to age and educational level have been found, but differences in knowledge according to sex are inconclusive. Ni et al. [20] showed that women had
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significantly better knowledge than men, while Artinian et al. [21] found no sex related difference. Patients b75 years had significantly better knowledge than older patients and higher education was associated with higher levels of knowledge [20,21]. These studies of educational interventions show that there is a gap between patients receiving and retaining information on self-care in heart failure. When teaching patients, it is crucial to be aware of and target the barriers to learning.
Table 2 Overview of the topics for education to patients with heart failure presented in the guidelines from the European Society of Cardiology [38] Topics for patient education ! definition and symptoms/signs of heart failure ! aetiology ! monitoring of symptoms ! self-management of symptoms ! daily weighing ! rationale for treatment ! adherence to treatment ! prognosis
Drug counselling
! drug effects/adverse effects/signs of intoxication ! administration ! drugs to avoid or be aware of, e.g., NSAID ! flexible diuretic intake
Rest and exercise
! ! ! ! ! !
rest exercise training work daily physical activities sexual activity rehabilitation
Dietary and social habits
! ! ! ! !
restricted sodium intake when necessary restricted fluid intake in severe heart failure avoid excessive alcohol intake smoking cessation reduce overweight
Vaccinations
! pneumococcal and influenza immunisation
Travelling
! air flights ! high altitude, hot/humid places
4. Learning needs In order to identify the education that patients with chronic heart failure need and want to have about their condition, patients should be involved in the development of educational materials and models. The educational needs of patients with heart failure have been evaluated using an instrument with eight dimensions called the Heart Failure Learning Needs Inventory [35–37]. Patients generally rated all items as very important and realistic to learn. Information on medication and signs and symptoms were ranked as most important, followed by general heart failure education, risk factors, prognosis, activity, psychological factors and diet [37]. In the guidelines on heart failure treatment from the European Society of Cardiology [38] several educational topics are listed as important for patient education (Table 2). The rationale for the specific areas is not completely
explained in the guidelines and there is a lack of evidence for several of the non-pharmacological interventions proposed, for example, fluid and salt restriction. Further, the guidelines only advise on what to teach, not how it should be done, e.g., educational models, material, provider and setting.
5. Education models Patient education can be defined as the process of improving knowledge and skills in order to influence the attitudes and behaviour required to maintain or improve health [39]. Patient education includes all educational activities directed at patients, including aspects of therapeutic education, health education and clinical health promotion [40]. The traditional model of learning assumes that education improves knowledge and that increased knowledge accomplishes a higher self-care behaviour, including improved adherence with pharmacological and non-pharmacological treatment. Furthermore, as a consequence of
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General advice
3. Barriers to learning Heart failure is a condition mainly affecting the elderly and the majority of patients are above 70 years of age [28]. In addition to heart failure, these elderly patients also suffer from other co-morbidities such as diabetes, chronic obstructive lung disease, ocular disorders, osteoarthritis, dementia and chronic renal failure [29], which can cause functional and cognitive limitations. The incidence of cognitive impairment among patients with heart failure over 65 years was 57%, compared to 20% in age matched controls [30]. Poor physical capacity and fatigue is also very common among patients with moderate to severe heart failure [31]. Patients suffering from heart failure have a higher prevalence of depression and anxiety [32,33]; many patients have a low self-esteem and perceive their care as incomprehensible [34]. This can lead to a low motivation and interest in learning how to perform self-care. Since many patients with heart failure live alone and have a poor social support [7], they do not have a spouse or carer, who can participate in the education process and provide support for self-care, thereby helping to overcome the previously mentioned barriers to learning. Examples of learning barriers and strategies to overcome them are given in Table 1.
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6. The process of patient education The process of patient education can be described in five steps. The first step includes an assessment of the patient’s previous knowledge, misconceptions, learning abilities, learning styles, cognition, attitudes and motivation. This can be done through an interview, a chart review and tests. After this assessment, the patient’s recourses, barriers and learning needs can be diagnosed. The third step is the planning of the education with the patient, goals are set and educational interventions are chosen. In the planning phase, the type of education, the frequency, who will deliver the education and when and how it should be given should also be addressed. The next step is delivery of the education, and the last step is the evaluation. Continuous evaluation of patient’s needs and goals provides the basis for further education. In addition to the individual evaluation, a more structured evaluation of the effects of patient education in, for example, a heart failure clinic provides valuable information about the quality of care [39].
7. Educational provider, setting and material Nurses and physicians or a multidisciplinary team including dieticians, pharmacists, social workers, psychologists and physiotherapists can provide education [13,42]. Heart failure nurses specialise in providing patient education and these nurses have the skills and motivation to provide
individualised, evidence-based education to heart failure patients. The role and specialisation of heart failure nurses are outlined in more detail in the paper by Blue and McMurray in this issue [43]. The venue for the education can be the hospital, the outpatient clinic at the hospital or in primary care, the patient’s home or a combination of all of these. Teaching often starts in primary care or in the hospital, depending of where the patient is diagnosed. Since many patients receive education at different times from different caregivers, the content of the education must be consistent throughout the chain of care in order to achieve greater compliance with treatment. Adherence has been shown to be decreased when patients receive unclear and contradictory information from health care professionals [44]. At the time of the diagnosis, many patients are not receptive to education since the diagnosis can trigger a crisis [45]. The most appropriate time for extensive education is when the patient is in a stable condition and has started to adapt to living with heart failure [46]. Most patients need repeated education, both because there is a large amount of information to be given and because the patients condition and treatment can change over time. Educational materials that can be used in combination with verbal information are written material such as books, booklet and newsletters, as well as other media such as videos, web pages and computer-based programmes. In addition to continuous face-to-face or computer-based teaching, telephone management or newsletters can also be used to reinforce education. Newsletters with information on the causes and manifestations of heart failure, medications, recommendations for diet and exercise can be mailed weekly or monthly to patients [47,48]. Educational interventions have also been combined with telemonitoring [49].
8. Educational goals The goals of education are to help the patient to actively participate in their own care, make informed choices about treatment and health care behaviours and engage in self-care with competence and confidence [39,50]. Education can make the disease and its symptoms more comprehensible to the patient. Knowledge increases perceived control and facilitates the patient’s adaptation to the chronic-illness role and self-care behaviour such as restricted fluid and salt intake, exercise, adhering to pharmacological treatment, monitoring symptoms and seeking assistance when symptoms of worsening heart failure occur [46,51].
9. Evaluation of patient education Education is an important component in disease management programmes, other components are optimised treat-
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this change in self-care behaviour, mortality, morbidity and health care costs are reduced. Increased knowledge does not necessarily correlate with improved adherence [20]. On the other hand, knowledge is not always needed for patients to be compliant with treatment or performing selfcare. It is common for patients to comply with medical treatment without knowing the names or the effects of the drugs. However, lack of knowledge can be problematic, for example, when a patient complies with self-care behaviour such as daily self-weighing and recording of weight, without knowing that weight gain could be a sign of deterioration. The criticism of this traditional model is that there is no learning without reflection, interaction, understanding and interpretation and that the patients’ self-efficacy, autonomy and perceived control have a great influence on this process [41]. It is important that the health care professionals providing education reflect upon their own attitudes and opinions about knowledge, learning and education as well as their treatment of the patient. Is the patient treated as a partner in learning or a pupil? Is there a dialogue with the patient regarding learning needs and thoughts or is it just a one-way communication with standardised material?
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because the instruments are only responsive to highintensity interventions and sensitive to major differences in symptom severity, but may not be sensitive to subtle differences. The number of patients with heart failure has increased dramatically during recent years. Hospitalisation, which is the major health care cost in this population, consumes a considerable part of the health care budget in general [5]. Health economic analysis is crucial for those prioritising and distributing resources in health care. In order to make a true economic evaluation, all health care costs need to be included and not just hospital readmission. Otherwise, costs can be moved from one sector to another, e.g., from hospital care to primary care [65].
10. Conclusion Patients with heart failure need education in order to adapt to their chronic condition and perform self-care behaviour. Despite the fact that many patients received education and perceived information about heart failure as important, they had low levels of knowledge and lacked a clear understanding of why they had developed heart failure, how it was defined and what relevant self-care behaviour should be performed. Findings on patient knowledge are similar in populations from both Europe and the United States. Educational interventions need to be designed for elderly patients with significant co-morbidity, fatigue and cognitive dysfunction. It is important to target barriers to learning such as functional and cognitive limitations, misconceptions, low motivation and self-esteem. Health care professionals need to be skilled in assessing the requirements and the level of education given to the individual. Heart failure education can be further improved by combining clinical experience with new technologies such as computer-based education, telecare and telemonitoring. The effect of new materials and methods needs to be evaluated and patients with heart failure should have an active role in this process. Patient education is an important component in heart failure care and should be provided through effective and well-evaluated strategies. Otherwise, the education can be a waste of time, both for the patient and the health care professionals, since received education does not automatically mean that information is absorbed or retained.
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