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2. METHODS

Chapter 5

Patient Education

Lone Kjems Brunse

5.1 Introduction

Patient education is defined as systematic communication of health knowledge and guidance to patients and their families. It is a cornerstone of cardiac rehabilitation.

Patient education in the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital includes group education, individual education and training of practical skills. This chapter describes the principles of the patient education, the heart-health meetings, which are arranged as a structured educational programme encompassing six meetings, and the supplementary instruction in cardiac resuscitation.

Patient education

Illustration af Patientundervisning


5.2 Evidence On The Effects Of Patient Education

Knowledge comprises an important aspect of lifestyle intervention but cannot stand alone (Chapter 3) (1). Two comparative studies on patient education for patients with heart disease (2;3) show that patient education is essential to give patients a qualified basis for making decisions and to increase their knowledge, but it is not sufficient to change lifestyle significantly. The quality of patient education depends on planning and on the use of principles especially related to social theories of learning: relevance to patients’ needs and resources, opportunity for individualization, feedback, reinforcement and facilitating behaviour change through skills and resources (4). Patient education should be combined with psychosocial support and lifestyle intervention to result in change in health behaviour. Similarly, knowledge of the disease and how people react to it are key components of psychosocial support (Chapter 9) but are not sufficient to improve psychosocial well-being (5).

Studies have shown that patients with heart disease seek knowledge on disease, treatment options and prognosis (6) and what they can do to prevent the disease or its progression (7;8). Health personnel in Denmark are obligated by law to inform and advise patients on these matters. According to the Act on Patients’ Legal Rights of 1998 (9), health personnel in Denmark must inform patients about their state of health and treatment opportunities, including opportunities to prevent disease, and the potential effects of not initiating treatment.

There is a consensus in Denmark that patient education should be part of comprehensive cardiac rehabilitation (10–12) and the rehabilitation of patients with type 2 diabetes who have a high risk of heart disease (13). Nevertheless, Denmark has no detailed guidelines for the content, form and extent of the education.


5.3 Purpose

The purposes of the patient education in the comprehensive cardiac rehabilitation programme are to provide patients with basic knowledge on their illness and how they can contribute to preventing or hindering the progression of the disease and to advise patients on how to master their disease.


5.4 Methods

5.4.1 Principles

Patient education in the comprehensive cardiac rehabilitation programme is based on several cross-cutting principles described in this section.

Adult education
The intervention, which aims towards strengthening patients’ ability to learn, is based on the principles of educating adults. This means that patients should be stimulated to define their needs and what types of knowledge they want.The educational process is determined by patients’ expressed desires and self-identified needs (14). Patient education in the comprehensive cardiac rehabilitation programme is based on patients exchanging experience, viewing their life situation and experience as a valuable resource and considering each patient’s readiness for learning.

Barriers to learning
Known barriers to learning are minimized when the programme of patient education is arranged, either in groups or individually. Before patients can be receptive to education, any mental problems must be tackled, patients’ pain must be treated optimally and their physical state must allow them to concentrate. Patients with special needs receive special attention, such as patients with impaired vision or hearing and patients not born in Denmark.

Group sessions
Patient education is mainly organized as group sessions. The educational sessions were inspired by a course developed by the Danish Heart Foundation and Sundhedshøjskolen (Health School) Diget (15) and adapted to the comprehensive cardiac rehabilitation programme. Patients are also offered a supplementary course in cardiac resuscitation.

The patients have education sessions with the professionals they know from the individual consultations, which creates continuity in the programme.This means that the patient, spouse or other family member and professional build trust during the sixweek programme. The group sessions have no more than eight patients plus any family members.

The instructor presides over the meeting and encourages patients to participate in constructive debate that allows questions and the exchange of knowledge and experience. For example, one patient described how he experienced the week after a bypass operation, and another patient described the warning signs he got before myocardial infarction. This stimulates the exchange of ideas among the other patients.

To create a secure atmosphere, the patients present themselves briefly and an agreement is made about the rules the group will follow. Finally, the instructor clarifies the purpose of the education by reviewing the topics to be discussed and then discusses patients’ expectations. The instructor tells the group that everyone has to maintain confidentiality and that each individual decides what information to relate to the group.

Der lægges vægt på, at alle skal kunne følge med. Det har vist sig, at mange patienter, som har talt med deres læge om angina pectoris gennem mange år, ikke præcist ved, hvad betegnelsen betyder. Fagsprog i undervisningen bliver derfor holdt på et minimum, men langsomt introduceres patienterne til ordvalg og forkortelser som angina pectoris, AMI, PCI osv., da patienterne før eller siden vil støde på ordene [se note].

Everyone has to be able to follow the group sessions. Many patients who have talked with their physician about angina pectoris for many years still do not know exactly what this means. Technical language is therefore minimized in the sessions, but words and abbreviations such as angina pectoris, acute myocardial infarction and percutaneous coronary intervention are gradually introduced since patients sooner or later will encounter these words.

Since the groups are randomly created across age, gender and course of illness, not all patients consider the content of the course to be equally relevant to them. The instructor attempts to adapt the set education programmes to the situation of each patient. The instructor regularly assesses which topics are most appropriately discussed in individual counselling.

Group effects: It is important for groups to keep attendance reasonably constant. High attendance stimulates both patients and instructors. The patients are therefore requested to notify the instructor if they are going to be absent. This request has turned out to have an inherent effect of increasing attendance.

Individual education
Patients who do not wish to participate in group education sessions or are considered to need a supplement to group education are offered individual education sessions. For example, patients in crisis and patients with a complicated course of illness would benefit from extra guidance, perhaps together with family members. This also applies to patients who do not speak Danish well, are hearing impaired, mentally unstable or for whom the group sessions are interrupted because of admission or illness. The relevant professional conducts the education and bases the sessions on the patient’s situation. Several professions are often involved, such as combining counselling with a physical therapist and a dietitian in a weight-loss programme.

Instructional aids
Education sessions use slide presentations in PowerPoint (Microsoft Office), flipover charts, a whiteboard and various models of the heart and the coronary arteries. The dietitian uses food packaging and blind tasting so that several senses are activated in the learning process. The education computer of the Cardiac Rehabilitation Unit is linked to the Internet, and relevant web sites are used as needed in education sessions. Further, the Unit has various video films on heart disease and treatment that patients can watch or borrow and watch at home.

Heart-health meetings
Meeting Topic Professional responsible
1 Development of cardiovascular disease Physician and nurse
2 Mental reactions associated with (the risk of)
cardiovascular disease and hospital admission
Nurse
3 Living with (the risk of) cardiovascular disease
– including pharmaceutical treatment
Nurse
4 A heart-healthy diet in daily life Dietitian
5 Physical activity in daily life Physical therapist
6 Changing lifestyle – what about daily life? Nurse


5.4.2 Heart-health meetings

Six heart-health meetings of 1.0–1.5 hours are held. Each meeting begins by briefly reviewing the agenda and the type of meeting, and the patients are informed that they can ask any questions they have during the meetings. Each meeting has a special education programme (available in Danish at www.CardiacRehabilitation.dk) with which the entire clinical team is familiar. Each professional takes responsibility for preparing and developing his or her own educational materials.


1. Heart-health meeting


Development of cardiovascular disease




Physician and nurse

Purpose
The purpose of the meeting is to give patients and family members insight into the factors that contribute to cardiovascular disease and related risk factors in accordance with the recommendations of the Danish Society of Cardiology.

The meeting
The patients are encouraged to introduce themselves by name and age and to describe very briefly their course of illness. Then patients get a nametag to place on their clothes. The introductions are arranged such that each patient can decide whether to participate. The patients are seeing one another for the first time, and some have never attended such courses before.

The physician starts by describing the physiological background for developing cardiovascular disease and indicates that arteriosclerosis is a universal phenomenon. Thus, the discussion is relevant to all patients even if they do not yet have signs of illness. Risk factors related to previous and present lifestyle are reviewed and discussed together with when and why pharmaceutical treatment is advantageous. Finally, the nurse explains the programme of heart-health meetings and gives the patients a written overview of the meetings (available in Danish at www.CardiacRehabilitation.dk) to put in their heart-health orientation binder. The nurse informs patients about the supplementary course on cardiac resuscitation and encourages them to participate.


2. Heart-health meeting


Mental reactions associated with (the risk of)
cardiovascular disease and hospital admission




Nurse

Purpose<
FThe purpose of this meeting is to give patients and family members insight into various types of mental reactions to hospital admission and cardiovascular disease. The meeting allows patients and family members to exchange experience based on their current desires and needs.

The meeting
The nurse explains that the education will focus on emotional reactions that may arise in connection with illness and hospital admission. The nurse emphasizes that there can be more than one way to tackle this situation, and not everyone experiences these emotional reactions.

The nurse defines the concept of crisis and reviews the phases of the crisis in relation to symptoms and duration (Chapter 4). Anxiety is explained, since anxiety can be a natural result of heart disease. This can include anxiety related to the future, falling asleep, physical activity, including resuming sexual activity, and other matters. Patients should understand that these reactions are quite normal. The nurse informs patients about the symptoms of depression and the importance of taking these symptoms seriously and seeking help when necessary. The nurse explains that spouses often experience the same phases as patients.

The patients are encouraged to exchange experience on how to cope with stress, crisis, anxiety, depression or other problems. Many patients really need to express how they have experienced illness, whereas others prefer to take action to cope with their problems.

The nurse adjusts the content of the meeting according to the composition of the group in terms of course of illness and present situation. Not everyone wants to share their feelings and thoughts with others in the group, and this wish is respected. If the nurse considers that some patients need to discuss their course of illness subsequently they are offered individual consultations. Similar, the nurse is aware that the meeting can promote a process of reflection that some patients may need to discuss later in the programme.


3. Heart-health meeting


Living with (the risk of) cardiovascular disease
– including pharmaceutical treatment




Nurse

Purpose
This meeting educates and guides patients in their symptoms and taking appropriate action based on these symptoms. The meeting also discusses pharmaceutical treatment and reviews selected risk factors in detail.

The meeting
Following up the theoretical explanation of cardiovascular disease at the first meeting, the nurse explains how individuals can cope with heart disease in daily life. Such symptoms as angina pectoris, breathlessness, impotence and intermittent claudication are explained. What should patients do when these symptoms arise? When should they seek health care professionals? Which procedures should they follow in daily life? The nurse ensures that everyone knows the effects and side effects of using nitroglycerin and other pharmaceuticals. If most of the patients in the group do not yet have heart disease, the nurse emphasizes risk factors for cardiovascular disease. The nurse attempts to include patient’s risk profiles as examples. When are blood pressure or serum cholesterol too high? What roles do smoking or overweight play?


4. Heart-health meeting


A heart-healthy diet in daily life




Dietitian

Purpose
This meeting gives patients tools to make conscious choices in purchasing situations. The focus is on the fat content of food, especially “hidden” fat and saturated fat. The taste and quality of food is discussed as well as traditions and habits.

The meeting
The dietitian encourages patients to suggest topics based on current problems. Based on the fat content of food, the dietitian explains how to read a food product label and the different between the percentage of fat in the food and the percentage of total energy deriving from fat. The meeting then discusses many common foods and the recommendations for the maximum percentage of energy intake from fat. The fat content of cheeses, processed meat and fish products and various cuts of meat is reviewed. The fat and sugar content of the currently available low-fat and low-sugar products is reviewed. The dietitian hands out material for help in shopping (a purchasing guide from the Becel® Programme, the Danish Heart Foundation or the Danish Diabetes Association and a fat-o-meter from the Federation of Danish Pig Producers and Slaughterhouses) and presents ideas on heart-healthy sandwiches (from the Becel® Programme). Patients’ potential rejection of low-fat margarine (versus butter and full-fat butter–oil blends) and low-fat cheese are discussed based on blind tasting.

The educational methods include slide shows, dialogue, blind tasting and demonstration of product packages. The dietitian includes as many senses as possible to strengthen the learning process. Patients are allowed to ask questions so that they can compare with their previous experience in such areas as shopping, cooking and following a specific diet.


5. Heart-health meeting


Physical activity in daily life




Physical therapist

Purpose
This meeting ensures that patients receive theoretical knowledge on physical activity with the aim of preventing heart disease. The educational process, similar to exercise training, is intended to encourage patients to adopt a more physically active lifestyle.

The meeting
The physical therapist emphasizes that everyone is expected to participate in the discussion and that all questions on physical activity are relevant. The physical therapist then explains the overall principles of exercise training in an attempt to promote discussion on exercise training and what it means to each person. Patients’ experience is incorporated in the meeting, and patients have the opportunity to draw parallels with the supervised exercise training.

Patients have an opportunity to express how they have experienced the previous 5 weeks of exercise training and can discuss the perspectives for the future. Numerous questions emerge during the meeting.Why should people be physically active? What physical activities are necessary? What intensity is sufficient? How can physical activity be implemented in everyday life? How can people maintain an appropriate level of physical activity in the future?


6. Heart-health meeting


LChanging lifestyle – what about daily life?




Nurse

Purpose
This meeting gives each patient the opportunity to evaluate the programme and their own efforts and to set new goals for changing and maintaining lifestyle based on their current situation.

The meeting
The meeting is based on the patients’ experience and thoughts. Each patient is encouraged to describe their individual programme and tell about changes they have initiated. Then the patients can discuss their thoughts.Will maintaining the changes after the intensive programme is over be difficult? What plans does each patient have for the future? The nurse considers the fact that everyone may not wish to describe their own efforts. Nevertheless, habits related to physical activity, diet and smoking are less taboo that such topics as crisis, anxiety and depression for most people.

The nurse informs patients about local activities and how these can support individual patients in changing lifestyle (included in Danish in the activity folder described in Chapter 9). These can include events held by the Danish Heart Foundation, events related to physical activity or smoking cessation and especially meetings that strengthen community with other people. The information is adapted to the group and the current needs of each patient..

Finally, the nurse informs patients about their relationship with the comprehensive cardiac rehabilitation programme in the following year, including clinical assessment by the physician and opportunities for individual follow-up among the various professionals in the clinical team.


5.4.3 Supplementary instruction in cardiac resuscitation

Studies show that both patients with heart disease and their close family members are interested in receiving instruction in cardiac resuscitation (16). Patients who have been resuscitated and family members who have witnessed cardiac arrest are especially interested in such instruction (17). Nevertheless, we found that very few family members actively seek instruction in cardiac resuscitation. Denmark’s departments of cardiology have not traditionally offered patients’ family members instruction in cardiac resuscitation even though patients with heart disease have an increased risk of cardiac arrest and about 70% of all cases of cardiac arrest occur at home (18).

The comprehensive cardiac rehabilitation programme developed a three-hour course in cardiac resuscitation for patients and family members to supplement the intensive programme. The instructional material was prepared in accordance with the international guidelines on basic life support for adults (19) and the recommendations of the Danish Heart Foundation (20). The group sessions have no more than eight people. Patients and family members are informed about and offered the course in cardiac resuscitation at the first heart-health meeting. The nurse teaches the course.

Course in cardiac resuscitation
Nurse

Purpose
The course teaches family members and patients about the causes of cardiac arrest, how to determine whether cardiac arrest is occurring and training in practical skills in cardiac resuscitation.

The course
The course is simple and includes only the absolutely crucial elements, to ensure that the participants remember the essentials. The goal is to get participants to feel ready to help in cardiac resuscitation and feel certain that they cannot do anything inappropriate. The participants can train at their own pace. Some participants are not strong enough to practise cardiac massage or to give artificial respiration; others have difficulty practising on the floor. The course considers individual needs.

Introduction (15 min.): Each participant is encouraged to describe his or her expectations on and reasons for taking the course. The nurse asks everyone whether they have witnessed cardiac arrest whether they have experienced cardiac arrest or have helped in cardiac resuscitation. This can help the nurse in considering individual needs in the course.

Theory (40 min.): The nurse explains the known causes of cardiac arrest. The participants are then shown how to determine whether cardiac arrest is occurring and how to treat it and how and when one should call for help. The nurse briefly reviews fainting (syncope), which looks similar to cardiac arrest, the recovery position and the chain of survival.

The chain of survival has four links: getting help early, early cardiac massage, early defibrillation and early advanced cardiac resuscitation. The family members learn to take action in the first two links. The nurse emphasizes that all four links are essential for optimum resuscitation.

The Chain of Survival

Illustration af OVERLEVELSESKÆDEN


Practical exercises (100 min.): The participants perform practical exercises in a large room with space for pairs of participants to practise. The exercises comprise:

  • Determining whether cardiac arrest is occurring;
  • Calling for help; and
  • Resuscitation (artificial respiration and cardiac massage)

The nurse demonstrates these techniques on a mannequin, and then the participants individually try to perform them. Each person has a mannequin available. The stepwise demonstration clarifies many questions during the course and participants learn much by observing one another. After the demonstration the participants pair off to practise determining whether cardiac arrest is occurring, calling for help and cardiac massage.The nurse supervises the participants and ensures that all participants practise all aspects.

Conclusion (10 min.): The conclusion includes discussion and answering questions arising during the course. All participants get a brochure on cardiac resuscitation (20), and the nurse explains the importance of participants regularly repeating the theoretical and practical skills.


References

(1) Froelicher ES. Multifactorial cardiac rehabilitation: education, counseling, and behavioral interventions. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. New York, Dekker, 1999: 187–191.

(2) Godin G. The effectiveness of interventions in modifying behavioral risk factors of individuals with coronary heart disease. J Cardiopulm Rehabil 1989; 9: 923–936.

(3) Cowan MJ. Cardiovascular nursing research. Annu Rev Nurs Res 1990; 8: 3–33.

(4) Mullen PD, Mains DA, Velez R. A meta-analysis of controlled trials of cardiac patient education. Patient Educ Couns 1992; 19(2): 143–162.

(5) Dusseldorp E, van Elderen T, Maes S, Meulman J, Kraaij V. A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychol 1999; 18(5): 506–519.

(6) Danish Regions, Copenhagen Hospital Corporation and Ministry of Health. Patienternes vurdering af landets sygehuse [Patients’ assessment of Denmark’s hospitals]. Glostup, Copenhagen County, 2000.

(7) Campbell N, Grimshaw J, Ritchie L, Rawles J. Cardiac rehabilitation: the agenda set by postmyocardial infarction patients. Health Educ J 1994; (53): 409–420.

(8) Duryee R.The efficacy of inpatient education after myocardial infarction. Heart Lung 1992; 21(3): 217–225.

(9) Lov nr. 482 om patienters retstilling [Act No. 482 of 1 July 1998 on Patients’ Legal Rights]. Copenhagen, Ministry of the Interior and Health, 1998.

(10) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(11) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(12) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(13) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(14) Maunsbach M. “One thing is something theoretical … quite another is practice!” Aspects of compliance and non-compliance among patients with type 2 diabetes. Dissertation. Aarhus, Department of General Practice, University of Aarhus, 1997.

(15) Rødkær C, Bergfors V, Hvid U. Kursus for hjerteramte familier, 7 døgns internatkursus. Sundhedshøjskolen Diget [Course for families of people with heart disease, 7-day course at Health School Diget]. Copenhagen, Eget forlag, 1990.

(16) Platz E, Scheatzle MD, Pepe PE, Dearwater SR. Attitudes towards CPR training and performance in family members of patients with heart disease. Resuscitation 2000; 47(3): 273–280.

(17) Kliegel A, Scheinecker W, Sterz F, Eisenburger P, Holzer M, Laggner AN. The attitudes of cardiac arrest survivors and their family members towards CPR courses. Resuscitation 2000; 47(2): 147–154.

(18) Årsberetning 2000 [Annual report, 2000]. Copenhagen, Danish Heart Foundation, 2001.

(19) Handley AJ, Becker LB, Allen M, Van Drenth A, Kramer EB, Montgomery WH. Single rescuer adult basic life support. An advisory statement from the Basic Life Support Working Group of the International Liaison Committee on Resuscitation (ILCOR). Resuscitation 1997; 34(2): 101–108.

(20) Hjertestop – din hjælp er livsvigtig [Cardiac arrest – your help is vital]. Copenhagen, Danish Heart Foundation, 2001.


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