Heart failure (HF) is a progressive syndrome characterized by high mortality, frequent hospitalizations, and a complex therapeutic regimen.1 A major component of the economic and societal burden imposed by HF remains recurrent hospitalizations, with 30-day readmission rates as high as 20% to 27%.2,3 Heart failure has been recognized as a potentially avoidable hospitalization,3 with HF consensus guidelines emphasizing self-care behavior adherence to improve patient outcomes and reduce readmissions.4,5 Patient education is highlighted as an important precursor to adhering to treatment plans and performing self-care behaviors.6,7 A variety of different educational interventions have been implemented; however, it is often difficult to compare interventions as some articles lack a precise program description.8 Difficulties have also arisen in determining the effectiveness of particular education strategies, as multiple strategies are commonly bundled together and packaged within research protocols.9 Although the most effective education approach for patients with HF has yet to be established, proven commonalities have been identified, which include assessment of learning needs, verbal interaction with a healthcare professional, and multimedia patient education materials.10 On the basis of these concepts, we developed a patient-centered multimedia educational strategy originally tested in a pilot study that demonstrated improved knowledge (P < .0001) and self-care abilities of maintenance (P = .027), management (P < .0001), and confidence (P = .051).11 This initial study was a 1-group pretest-posttest design using a convenience sample. All participants attended an outpatient session to receive education, and the follow-up was only 8 weeks. As this study provided some evidence of the effectiveness of the education strategy, we wanted to apply this approach for both inpatient and outpatient settings. Therefore, we designed a randomized controlled trial to further investigate the effectiveness of this multimedia educational intervention for patients with HF. This article aims to describe the study and, in particular, provide sufficient information regarding the educational intervention to inform practice. Many reported studies lack a precise description of the intervention, making comparative analysis or replication difficult.8
Objectives and Hypothesis
The aim of our study is to determine the effectiveness of a multimedia educational intervention for patients with HF in reducing unplanned hospital readmission. In addition, this study aims to investigate whether patients who participate in this educational intervention demonstrate improvement in their knowledge and self-care abilities. We hypothesize that for patients with HF, an individualized multimedia educational intervention is superior to usual care with regard to unplanned hospital readmissions (primary outcome). In addition, we expect patients with HF who participate in this educational intervention will demonstrate improved knowledge of HF and improved self-care health related behaviors (secondary outcomes).
Andragogy outlines 6 core principles of adult learning that enable us to apply a learner-centered process tailored specifically to adults for the development of educational interventions. Knowles, the founder of andragogy, highlighted that learning should focus on the learner and defined learning as the process of gaining knowledge and/or expertise.12 Andragogy is based on the following precepts: Adults need to know why they need to learn the information, they are responsible for their own lives, they have life experiences, they will have a readiness to learn things they need to know to cope effectively with real-life situations, they are life centered in their orientation to learning, and they are responsive to internal rather than external motivators.12 Applying the principles of andragogy fosters education interventions that acknowledge the adult learner, incorporate a needs assessment, and support development of knowledge and skills for self-management.12 The value of an educational intervention will be affected by how well it fits the needs of the intended leaner. The outcome of the education process is achieved when learners are able to participate in the learning process to develop knowledge and become active partners in their ongoing self-management. The success of the intervention depends not on the quantity of information delivered but rather on demonstrated knowledge development and ability to implement appropriate self-care behaviors. In this study, this will be evidenced by the responses to the teach-back evaluation questions at the end of the educational intervention as well as the knowledge and self-care outcome measures.
A randomized controlled trial design was used in a single centre tertiary referral hospital.
Setting and Participants
Our study screened and recruited patients who were referred to the HF Management Program at the Princess Alexandra Hospital, Brisbane, for comprehensive management of their HF. Recruitment commenced in July 2012 and finished in March 2015. Patients were enrolled from inpatient wards or outpatient clinics. Exclusion criteria were as follows: unable to read and write English, visual or hearing impairment limiting the use of the DVD, significant cognitive impairment, living in a residential aged care facility, being considered for transplantation or artificial heart device, or diagnosed with a terminal malignancy.
The primary outcomes are all-cause unplanned readmissions documented at 28 days, 3 months, and 12 months after recruitment. An unplanned hospitalization has been defined as an unplanned overnight stay in hospital. We will also report if the readmission was a HF hospitalization, defined as a hospitalization caused by substantive worsening of HF symptoms and or signs requiring the augmentation of oral medications or new administration of intravenous HF therapy.13 An independent review committee of 3 clinicians who are blinded to the allocation of the intervention reviewed all reported hospitalization data.
The secondary outcomes are changes in knowledge and self-care behaviors assessed at baseline and 3 months and 12 months after recruitment.
Knowledge of HF was assessed with the Dutch Heart Failure Knowledge Scale (DHFKS).14 This is a 15 item multichoice questionnaire concerning HF knowledge in general, knowledge on treatment, symptoms, and symptom recognition. The scale has a minimum of 0 (no correct answers) and a maximum of 15 (all answers correct). This instrument is able to differentiate between people with high and low levels of HF knowledge and has demonstrated face, content, and construct validity.14 This questionnaire has been used to evaluate the effect of an educational intervention in patients with HF.15
Self-care behaviors were assessed using the Self-care of Heart Failure Index (SCHFI) v 6.2.16 This instrument uses 3 subscales of self-care: maintenance, management, and confidence. The raw scores for each subscale are standardized to a range of 0 to 100 points, with a score of 70 or more required to determine self-adequacy.16 The subscale of management is completed by the patients only if they have experienced symptoms of breathing difficulty or ankle swelling over the previous 4 weeks; therefore, not every participant completes this subscale. The SCHFI is a valid and reliable measure of self-care and has been widely used in HF research studies.15,16 The Figure shows the recruitment and follow-up protocol.
Assessment, Randomization, Intervention, and Usual Care
After obtaining informed consent, all participants completed the 2 questionnaires: the DHFKS and the SCHFI. Baseline demographic and clinical data, including age, gender, etiology of HF, and functional classification, were also collected.
A randomization protocol allocated participants on a 1:1 basis to usual care or the multimedia educational intervention. We randomized patients by concealed allocation based on a computer-generated sequence to receive usual care or the educational intervention. The allocation was concealed in an opaque envelope. After baseline data collection, the sealed envelope was opened by the researcher to reveal the allocation of the patient to either usual care or educational intervention. If the participant was allocated to the educational intervention, this was undertaken by a specialist HF nurse. The specialist HF nurse who delivered the educational intervention was either the clinical nurse consultant or the nurse practitioner in our HF service. Both nurses are senior clinicians with extensive experience the management of patients with HF and both have a master’s degree. We limited the number of nurses delivering the educational intervention for this study to ensure standardization.
Andragogy has provided the framework for the development of this educational intervention. It is well recognized that developing interventions without a clear theoretical foundation is unlikely to achieve the desired learning outcomes.17 Our previous research investigating the learning style, learning needs, and learning preferences of people with HF has contributed to the development of this intervention.18,19 This research revealed that the patients with HF prefer patient information that is targeted to their needs, simple and succinct. They preferred to learn from a healthcare professional with resources that they can keep and return to later to refresh their learning. Reinforcement of information through repetition was acknowledged as assisting them to learn and remember information. Our work has highlighted that patients with HF preferred verbal information together with multimedia resources. Effective patient education comprises the provision of appropriate healthcare information in a format tailored to the patient’s learning needs and style.20 Compared with verbal information alone, written patient education resources have been demonstrated to significantly increase knowledge21 as well as to enhance patient confidence in managing their condition and seeking assistance when required.17
This educational intervention began with a needs assessment using responses from the 2 baseline questionnaires (DHFKS and SCHFI) to determine the participant’s learning needs. Questions that were answered incorrectly were noted on a template, which recorded the concept associated with that question. For example, if patients indicated that they did not know how often to weigh themselves or why it was important to weigh themselves in the knowledge test and also indicated they were not weighing themselves every day in the self-care questionnaire, this was noted under the concept “self-care.” When the intervention was delivered, time was spent discussing self-care. Educational concepts and self-care behaviors that the participant did not understand were grouped together under a common theme and a written plan was generated using a template. The plan had 6 themes: all about HF, symptoms, self-care, medicines, diet, and exercise, which closely related to the manual and the DVD chapters. The session began with the participant and the specialist HF nurse viewing the DVD together on a portable DVD player. This usually occurred at the bedside but occasionally in another setting such as a clinic room. The DVD could be stopped at any time to answer questions, clarify information, or individualize the role-modeled self-care behaviors to the patient’s individual setting. The verbal session, which followed, adhered to the written plan developed from the identified learning needs. If the participant had demonstrated knowledge for that theme, this was only briefly reinforced so that deficits in the areas of knowledge and self-care behavior could be the main focus of the session. The teaching strategy was interactive. The manual was used as a learning aid to reinforce the verbal information with pictorial visualizations. For example, the manual contains a colorful illustrative table to help participants to choose low-salt foods where required.
At completion of the educational session, a teach-back approach was used to determine the participant’s understanding of HF and appropriate self-care behaviors. The nurse asked the following question: “I know you have family and friends who may not know about heart failure. How would you explain heart failure to your (wife/husband/friend)?” There were 5 expected responses, which correspond to the sections on the written plan (HF, self-care and symptoms, medicines, diet, and exercise). The participants were prompted to provide answers for each section. The score for the teach-back questions and the time taken to deliver the education session were recorded. The length of each teaching session varied between 60 and 90 minutes. The participant was provided with the DVD and the booklet to continue to use as learning resources at home. The use of these resources by the participant is documented at the 3- and 12-month follow-up.
The educational intervention in this study incorporates 2 patient education resources: the GO-Getting on With Heart Failure manual and the So You Have Been Diagnosed With Heart Failure… DVD. These resources were specifically developed for patients with HF.22 The development of this manual was guided by the principles of adult learning recognizing the self-directed nature of adult learners. Decisions regarding presentation and the style of the manual were guided by instructional design and guidelines aimed at enhancing readability and patient engagement.9 The content development of this manual was guided by the patients’ identified learning needs,19 expert clinicians’ advice, evidence-based guidelines, and published literature. The manual is divided into 5 sections (All About HF; Symptoms; Treatment Including Self-care, Medicines, Diet, Physical Activity; Feelings; and Outlook). Each section contains written materials, pictures, and stories from HF patients and is written at grade 6 level or below to ensure that patients with low levels of health literacy will be able to read and understand the content. Each chapter concludes with 10 multiple-choice questions to stimulate knowledge development. The answers to the questions are available at the end of the manual to promote self-directed learning and provide timely feedback.
The DVD is specifically focused on implementing and role-modeling self-care activities through 8 “how-to” scenes (the hospital experience, self-care, medicines, daily weigh, rest and relaxation, food, and exercise). The DVD plays for 30 minutes; however, patients can select to play individual chapters if they prefer. Video education for patients with HF has previously increased adherence to self-care behaviors especially when patients experience worsening symptoms.6 Videos or DVDs provide a useful adjunct for patient education by role modeling appropriate self-care behaviors.
Patients allocated to usual care received the standard education, which currently includes pamphlets, a brief booklet about HF, and education by specialized HF nurses.
All statistical analysis will be performed using Statistical Package for the Social Sciences version 18 for Windows (SPSS Inc, Chicago, Illinois). Descriptive statistics will be used to describe baseline demographics, clinical characteristics, and outcome data (readmissions and DHFKS and SCHFI scores). Paired t tests will be used to determine pre-post changes in scores for knowledge and the self-care subscales maintenance, management, and confidence. Pearson χ2 will be used to detect the association between 2 categorical variables. The level of significance of .05 is used for all the tests in the analysis with 2-sided P values.
A total of 200 patients are enrolled in the study and are being followed up for 12 months: 100 were randomized to usual care and 100 were randomized to educational intervention. A total of 162 patients are required to have an 80% chance of detecting, as significant at the 5% level, a 20% decrease in unplanned readmission. We assumed a 40% event rate in the control group based on previous studies with a 20% decrease in events considered both realistic and clinically relevant.23 Allowing for a 20% loss to follow-up due to death, withdrawal, or drop out, we decided on a sample size of 200.
The appropriate institutional research ethics review committees have approved this research and informed written consent was obtained before participation by all participants.
This study received financial support from the Princess Alexandra Research Foundation and Private Practice Trust Fund.
This study is evaluating the effectiveness of a targeted multimedia educational intervention. Study results will contribute to a better understanding of the impact of an individualized needs assessment, multimedia education, and teach-back evaluation strategy on patient outcomes. Previous research investigating educational interventions for patients with HF has not clearly established a standardized approach or articulated the process undertaken to deliver the education to improve patient outcomes. With this study, we hope to provide evidence that a patient-centered approach incorporating the elements of learning needs assessment, individualized written plan, multimedia resources, and teach-back strategy is effective in improving patient outcomes. This approach is practical and reproducible and could be generalized as it does not require advanced technologies or additional equipment. We hope that the descriptions in this article give sufficient information for other healthcare professionals to translate this intervention to their own settings.
* Education interventions for HF patients are more likely to be effective when clinicians use the principles of adult learning.
* Education strategies should include individualized needs assessment, multimedia resources, and teach-back evaluation strategies.
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