Concise Appraisal of Qualitative Research Article
| Title | Concise Appraisal of Qualitative Research Article | Prefered Language style | English (U.S.) |
| Type of document | Article | Number of pages/words | 2 Pages Double Spaced (approx 275 words per page) |
| Subject area | Nursing | Academic Level | Undergraduate |
| Style | APA | Number of sources/references | 4 |
| Order description: | |||
| Write a summary and concise appraisal of the study. Use the APA format with title page, 3-4 paragraphs for summary and critique (300-400 words), and the complete reference at the end. Utilize Chapter 14 in your Fain, (2017), book as your guide. First Paragraph: Write a brief description or summary of the work cited including:•the level of research evidence (based on Melnyk and Fineout- Overholt’s Level of Evidence Scale in Module 1 under Dr. Poole’s video link)•purpose•type of qualitative study•major findings or themes•author’s conclusionsRemember to cite the authors and year in the first sentence of the first paragraph. The summary should be primarily in your own words, with paraphrased segments, except for the purpose of the study which may be word for word.Paragraphs 2 – 3: Analyze the work’s quality using the Critical Appraisal Guidelines: Qualitative Studies section in Fain, (2017) Chapter 14 with additional guidance starting on page 325 for some sections. Answer at least ONE question under each category below:•identified problem for study•purpose and research questions•literature review•sample and sampling procedure/technique including protection of human subjects•methodology•data collection procedures•data analysis: organizing/categorizing/summarizing•scientific integrity: credibility/transferability/dependability/confirmability•results of the study•findings•discussion of findings•evaluation summary including applicability to replicate or apply study findings in your area of practice whether that be a hospital, home health or SNF, etc.Say what is good, but also be critical and find something wrong! Try to be concise and non-repetitive.Last Paragraph: In your own words, discuss how this study relates to evidence-based practice and its implications for or impact upon nursing. Comment on what unique findings or insights that this study provided. If you chose a study outside the United States, how does potentially socialized medicine affect whether the study could be conducted in the United States and if you believe the findings would be the same or different and whyORIGINAL ARTICLE Educational strategies and challenges in peritoneal dialysis: a qualitative study of renal nurses’ experiences Manuela Bergjan and Christiane Schaepe Aims and objectives. The aim of the study was to explore renal nurses’ experiences, strategies and challenges with regard to the patient education process in peritoneal dialysis. Background. Patient education in peritoneal dialysis is essential to developing a successful home-based peritoneal dialysis program. In this area research is scarce and there is a particular lack of focus on the perspective of the renal nurse. Design. Qualitative design formed by thematic qualitative text analysis. Methods. Five group interviews (n = 20) were used to explore the challenges peritoneal dialysis nurses face and the training strategies they use. The interviews were analyzed with thematic qualitative content analysis using deductive and inductive subcategory application. Results. The findings revealed the education barriers perceived by nurses that patients may face. They also showed that using assessment tools is important in peritoneal dialysis patient education, as is developing strategies to promote patient self-management. There is a need for a deeper understanding of affective learning objectives, and existing teaching activities and materials should be revised to incorporate the patient’s perspective. Patients usually begin having questions about peritoneal dialysis when they return home and are described as feeling overwhelmed. Adapting existing conditions is considered a major challenge for patients and nurses. Conclusions. The results provided useful insights into the best approaches to educating peritoneal dialysis patients and served to raise awareness of challenges experienced by renal nurses. Findings underline the need for nosogogy – an approach of teaching adults (andragogy) with a chronic disease. Flexibility and cooperation are competencies that renal nurses must possess. Relevance to clinical practice. Still psychomotor skills dominate peritoneal dialysis patient training, there is a need of both a deeper understanding of affective learning objectives and the accurate use of (self-)assessment tools, particularly for health literacy. Key words: chronic diseases, content analysis, end-stage renal disease, nephrology nursing, patient education, peritoneal dialysis What does this paper contribute to the wider global clinical community? • Findings illustrate the educational barriers that patients face and highlight the importance to take in a special kind of adult education for patients with chronic diseases. • A thorough assessment can help to identify resources and barriers to learning such as uremia, language barriers and physical limitations. • Overall, the results of the study highlight useful strategies of nurses when ‘doing patient education at home’. Accepted for publication: 5 December 2015 Authors: Manuela Bergjan, Dr. phil, RN, Senior Lecturer in Nursing Education, Institute of Health and Nursing Science, Charite – Universitaetsmedizin Berlin, Berlin; Christiane Schaepe, RN, MPH, Research associate, Institute of Health and Nursing Science, Charite – Universitaetsmedizin Berlin, Berlin, Germany Correspondence: Christiane Schaepe, Research associate, Institute of Health and Nursing Science, Charite – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Telephone: +49 30 450 529 098. E-mail: christiane.schaepe@charite.de © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1729–1739, doi: 10.1111/jocn.13191 1729 Introduction End-stage renal disease is the fifth stage of chronic kidney disease (CKD) and the prevalence is expected to increase due to the rise of diabetes mellitus, cardiovascular disease and obesity, and the aging population (Kaptein et al. 2010). The options available for patients with CKD stage 5 include transplantation, peritoneal dialysis (PD), haemodialysis (HD) or conservative care. While PD patient outcomes are at least as good as with HD (Lameire & Van Biesen 2010), PD offers several benefits. It allows patients to perform and self-manage their treatment and care in their own home (Curtin et al. 2008), and it means they are not dependent on healthcare staff and do not have to travel to the clinic several times a week. It has been shown that PD can reduce costs e.g. in the UK healthcare system (Baboolal et al. 2008). However, although the benefits of PD are abundant and well documented within NICE guidelines 2011 (NICE 125), in particular patient education raises multiple demands for patients and nurses as educators. The biggest is probably to enable PD patients to handle over 90 percent of their care by themselves (Hall et al. 2004) while leading a normal life and dealing with the stress caused by the changes to their previous routine. Although adult patients are usually motivated to learn, in particular their characteristics and possibilities are very heterogeneous and challenging. Barriers to learning in PD patients might include cognitive impairments caused by advanced uremia (Crowley 2003), physical impairments caused by chronic fatigue and loss of strength, energy (Borras et al. 2006) or motivation (Paudel et al. 2014). Loss of memory is a source of frustration for both the learner and the teacher, especially when other barriers to learning are present (Thomas 2013). Vulnerable patients such as those with lower educational status, the elderly and those with multiple comorbidities need more time to acquire self-care skills and are more likely to develop peritonitis (Borras et al. 2006). The complex language used in PD therapy can cause problems in training, and some patients might be frightened about dialyzing themselves at home (Thomas 2013). Furthermore, in PD patient education it should be considered, that patients might be suffering from psychological issues related to the loss of self-esteem and selfimage, worrying about the future, and having to make psychological and behavioral changes (Kaptein et al. 2010). Being dependent on technology for survival is also a psychological burden, and the presence of the abdominal catheter might disrupt the patient’s body image (Partridge & Robertson 2011, Tong et al. 2013). Background Professional PD patient education is key to addressing these aspects and responding adequately to the educational challenges. The International Society of Peritoneal Dialysis (ISPD) recommends that nurses provide the education (Bernardini et al. 2006). Nurses therefore play an important role in PD therapy, as patient education is crucial to reducing the occurrence of peritonitis and dropouts, improving technique survival and other outcomes such as non-adherence and quality of life (Piraino et al. 2011, Schaepe & Bergjan 2015). Worldwide there is a wide variation in practices for PD patient training programs, especially in time and duration, methods and teaching aids and setting (Schaepe & Bergjan 2015). However, there is more accordance about the content of PD training recommended by the ISPD (Bernardini et al. 2006). Content focused mainly on technical skills such as aseptic technique, hand washing, masking, steps in exchange procedures, exit-site care, complications and troubleshooting. Case and disease management programs have been shown to have positive outcomes for individuals receiving PD (Schaepe & Bergjan 2015). Current recommendations say that principles of adult learning are the best basis for effective PD education programs (Hall et al. 2004, Bernardini et al. 2006, Finkelstein et al. 2011). The study of Hall et al. (2004) showed that applying adult learning theory and educational principles improves some but not all patient outcomes. In part, the study focused on the learners’ needs and used different strategies for different levels of learning in the cognitive, psychomotor and affective domains of learning. It also provided tools to engage learners according to their perceptual style (Hall et al. 2004). An important aspect to consider is that the learner in PD therapy is a patient with a long term condition who requires a special teaching method. Ballerini and Paris (2006) proposed the term nosogogy to describe the science of teaching adults (andragogy) who have a chronic disease (derived from the ancient Greek word ‘nosos’, meaning ‘disease’). There are differences between andragogy and nosogogy. Adult patients with a long term condition ‘will be asked to adhere to multiple life requirements’, because PD therapy influences all aspects of life such as habits, relationships or work. They strive to be less dependent on health professionals, but often have less learning resources as healthy adults. Patients cannot choose their learning contents and objectives. They learn what nurses expect them to and what they need to know, in © 2016 John Wiley & Sons Ltd 1730 Journal of Clinical Nursing, 25, 1729–1739 M Bergjan and C Schaepe order to be able to perform the therapy (Ballerini & Paris 2006: 124–125). The ISPD’s recommendations for PD patient education (Bernardini et al. 2006) are mostly based on theory and opinion and little empirical research has been done since then (Bernardini et al. 2006). Evidence-based PD patient training is therefore lacking, and there is a recognized need to promote PD by stimulating relevant education and research (Lameire & Van Biesen 2010). Furthermore, previous studies on educational interventions in kidney disease have been classed as suboptimal (Mason et al. 2008). Thus, qualitative research is needed to provide a deeper understanding of this complex nursing task. The perspectives of PD nurses on their experiences of PD education, the strategies they apply and the challenges they face can provide valuable insight into their knowledge and expertise. This could help develop future PD curricula and educational interventions for other chronic diseases. This study therefore aimed to explore PD nurses’ experiences, strategies and challenges with regard to the patient education process. Methods Participants and setting This study used a qualitative research approach to meet its aims. The underlying theoretical framework of qualitative content analysis is communication theory (Watzlawick et al. 1967), which benefits are acknowledged for nursing research and education by Graneheim and Lundman (2004). The communication act between researcher and participants goes on during describing, structuring or interpreting the texts based on interviews. The researcher must ‘let the text talk’ and can get valuable insights into participants’ knowledge and expertise in PD patient education. The participants all had experience of PD patient and nurse education. To get a broad perspective, they were recruited from nephrology wards in a university hospital (n = 3, group interview 1), from Baxter Germany (n = 9, group interview 2 and 3) and from dialysis clinics (n = 8, group interview 4 and 5). The hospital participants were selected on the basis of their positive responses to study information provided in their workplace. The participants from the dialysis clinics and from Baxter Germany were asked if, given their long experience of PD education, they would like to participate voluntarily. It is their ordinary task to train patients, which takes place either at the clinic or occasionally at the patient’s home. The interviews were pilot-tested with four participants. Two researchers were always present during the interviews, which each lasted around 90 minutes. Notes were taken directly after the interviews to record key statements made by the participants. Data collection Five semi-structured group interviews (n = 20) were conducted with the PD nurses between May and June 2013. An interview guide provided direction for the interview, which used open-ended questions to elicit information. The main topics addressed in the interview guide were: the participants’ strategies for teaching patients; the educational challenges that patients face when learning new skills; the challenges that trainers face when educating patients; positive and negative learning conditions; strategies for training PD trainers. This last theme will be presented elsewhere. Ethical consideration The study was granted permission to collect data and received approval from the data protection supervisor and from the staff council representatives of the participants’ employers. Due to the reason that no patients were involved in the study, it was not mandatory to seek ethical approval from a research ethic committee. However, we followed the Ethical Principles for Medical Research Involving Human Subjects, which were adopted in the Declaration of Helsinki (World Medical Association 2013). It was emphasized that participation was voluntary. All participants received oral and written information on the aim of the study and on the data security procedure. Written informed consent, including consent to audiotaping, was obtained from all participants via the signing of a consent form prior to each session. To ensure privacy and the quality of the data, the interviews took place in a quiet room, away from the participants’ place of work. Data analysis All interviews were taped and transcribed verbatim. Identifying information, such as name and place of work, was replaced with code numbers. Analysis was done with the software MAXQDA 11 VERBI Software GmbH, Berlin, Germany and carried out by both authors. Two data coders were involved in each step of analysis and consulted with one another to reach consensus where necessary. The interviews were analyzed with thematic qualitative text analysis using deductive category and inductive subcategory application (Kuckartz 2014). This is illustrated in Fig. 1. The first step involved reading the transcripts several times to obtain a sense of the whole and to become immersed in the data. © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1729–1739 1731 Original article Educational strategies and challenges in PD Next, a categorization matrix (see Table 1) was developed by choosing nine main categories (‘wh-questions’) based on the common components of the education process used in, e.g. the ASSURE model (Bastable 2003) and the ISPD guidelines for PD patient training (Bernardini et al. 2006). Two further categories were chosen that were based on the nursing didactics described by Fichtmuller and Walter € (2007). They use the term ‘critical action problems’ (CAPs) to describe the challenges and uncertainness that arise in clinical learning contexts and to which learners can respond by engaging in training that will adapt their skills. Our assumption is that the learning activities developed by PD nurses in CAP situations will be beneficial to managing challenges in PD patient education. The two researchers agreed on the definition of the mutually exclusive main categories, example quotes and coding rules. They coded independently and deductively according to the wh-questions and CAPs, and reviewed their work jointly. A second step involved inductively generating subcategories. To improve the presentation, the CAP categories were assigned to the respective wh-question categories. Results This section presents the main findings of the interviews. CAPs will be presented together with the wh-questions based on the components of the education process. For the purposes of readability, some of the main and the subcategories are presented under the same heading (non-professional actors, learning content and objectives, teaching activities and instructional materials and learning environment). This is illustrated in Table 1. Non-professional actors Patients Peritoneal dialysis nurses use the patients’ learning background as a resource in training. All interviewees emphasized the importance of tailoring the training to fit the individual. However, they also said it was hard to assess a patient’s ability and readiness to learn: Then, I don’t know, I go away, but how will he get on? (…) I’d like to have more time, be able to go back and follow up two or three weeks later. (group interview 2) A thorough assessment can help identify barriers to learning early on. Barriers mentioned often in the interviews were uremia, language barriers, physical limitations in elderly patients and the course of the long term condition itself: With the first patient, I ran through the whole program before I realized that he couldn’t take it in – he’s just too preoccupied with his disease. (group interview 4) Figure 1 The basic process of thematic qualitative text analysis (Kuckartz 2014: 70). © 2016 John Wiley & Sons Ltd 1732 Journal of Clinical Nursing, 25, 1729–1739 M Bergjan and C Schaepe Peers Experienced PD patients are occasionally used for peer support. They help with decision-making in the pre-dialysis phase, at clinic information sessions, and during home visits: We take in experienced patients to visit experienced dialysis patients at home. It’s a really successful approach. (group interview 4) Providing space for patients to engage in mutual exchange is considered beneficial because it responds to their need to meet and interact with their peers: When I hear my patients counseling the new ones, it’s clear they’re the experts. They’re much better at it than I am. (group interview 4) Relatives Relatives participate in training when they are needed as interpreters or want to support the patient. However, they are not always interested in being involved and can even disrupt the training: Sometimes you have these helping husbands – they come in with the video camera: “I’ll record everything, darling, and play it back for you later (…).” That kind of thing is obviously disruptive. (group interview 3) Learning content and objectives This section presents the findings on training content and on the psychomotor, cognitive and affective objectives (domains of learning). The PD nurses emphasized that practical skills, especially those related the bag exchange, have to be taught and should take priority over theory-based topics: The bag change is the most important goal. He needs to be able to flush out the fluid from his abdomen and refill it with fresh solution – and he has to be able to do it hygienically. (group interview 3) Why should I teach a 77-year-old man the basics of anatomy? That’s nonsense. It’s of no interest to him at all. (group interview 4) Table 1 Main topical categories and example subcategories of the content analysis presented in the article Deductive main categories*(2) Inductive subcategories*(4) Heading in the article* Wh-questions Definition Example of subcategories Example quote (7) Who? Learners and their characteristic traits Uremic patients ‘They’re often so uremic that they just don’t get it’ Non-professional actors From whom? Educators (professionals, non-professionals) Patient as teacher ‘We take the new patient to visit an experienced patient at home (…)’ With whom? People who assist trainers, or another learner Relatives ‘I had a Greek patient (…) and his daughter assisted with his training’ What for? Learning objectives & outcomes Affective learning objective ‘They’re really frightened, and I believe our job is to remove that fear’ Learning content and objectives What? Content of the training program Bag exchange as an essential topic ‘The bag change is the most important goal. He needs to be able to flush out the fluid from his abdomen and refill it with fresh solution’ With what? Teaching and learning aids Visual media, pictures, pictograms, icons ‘I think pictures, useful pictures, are ideal. Simple things with not much text’ Teaching activities and instructional materials How? Teaching and learning methods Simulation ‘I made a fake patient stomach out of a plastic infusion bag (…)’ Where? Place where learning occurs, and the conditions of that place Conditions at home ‘I would prefer training at home, to train them in their own environment’ Learning environment *(2), (4), (7): numbers of steps in the content analysis see in Fig. 1. © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1729–1739 1733 Original article Educational strategies and challenges in PD With regard to hand hygiene, the interviewees said challenges included patients not understanding when to do it, discrepancies in the instructions given to patients, and errors creeping into existing practice. As a cognitive objective, getting patients to understand anatomy in a scientific way is not considered as important as ensuring that they understand the basic regulating principles of the renal replacement therapy. They should be able to recognize deviations from the norm, understand possible complications and know what to observe and when to call for professional help: They need to contact the dialysis clinic in good time if something goes wrong. (group interview 5) Beyond the domains of learning, the patients and their relatives have to adopt self-management skills. Patients must react appropriately to complications, mange the logistics of their PD equipment, and document their therapy. Affective objectives are about changing patients’ attitudes and emotions. PD nurses aim to help patients accept the therapy and alleviate their fears so that they can develop the confidence they need to self-manage their PD: They’re really frightened, and I believe our job is to remove that fear. (group interview 3) The interviewees said that patients can participate in determining the content of their training. Issues important to patients include those related to everyday life, such as diet, physical activity, leisure time and vacations. Patients also need to be able to discuss body-image disturbances during training. They often dislike the foreignness of the catheter and find it hard to accept the way their body now looks: At the end of the day, it’s a foreign object. Somehow they’ve got to accept it – this thing coming out of their stomach. (group interview 3) Nurses rarely raise issues of sexuality, fertility and partnership because they feel they are too difficult to talk about. However, given that patients raise these topics themselves, they are clearly important to them: If patient doesn’t bring it up, I don’t address it. (group interview 4) Teaching activities and instructional materials This section describes the teaching activities and instructional materials that PD nurses use to facilitate learning. Our findings indicate that nurses hold that it is important for training to follow the patient’s needs. The first step is for the nurse and patient to get to know each other by reviewing medical records, work history or learning background. Next, patients can familiarize themselves with the material and the PD procedure. Demonstration and instruction are the most widely used teaching activities. However, patients can become confused and overwhelmed if several trainers are involved and each of them demonstrates things differently: Here’s a silly example: Imagine I’m showing you how to pour a glass of lemonade. I might tell you that you have to do it like this, but then I might say, “Of course, you can also do it like this. And if you want, you can do it from the other side” (demonstrates pouring the drink). Then someone else comes along and says, “That’s not right – you have to do it this way!” That’s often what it’s like for us with PD/…/. It’s ridiculous. The goal is to connect the bag hygienically and, to be honest, there are thousands of ways of doing that. (group interview 3) Some PD nurses said talking and note-taking should be kept to a minimum during training. Instead, the focus should be on practicing the bag exchange until it becomes routine: It’s best to say nothing at all – just let him try it, then demonstrate again, then let him try it, and keep quiet the whole time. (group interview 2) The interviewees felt that judging the effectiveness of the training was a critical point. It can be done by asking patients directly about what they have retained or by leaving the room during training so that they have to manage alone (but can call for help if necessary). Patients are trained early on with real-life resources and using their own catheter. Here, the role of the PD trainers is to observe and give occasional guidance: Sometimes I guide the patient’s hand. I hold the patient’s hand with mine so that nothing can happen. (group interview 2) Artificial resources, such as practice catheters, aprons and homemade materials, can also be used. These have the advantage of allowing patients to avoid negative consequences if they make mistakes. Some interviewees, however, criticized this approach for not being realistic and argued for training exclusively with the real catheter: I made a fake patient stomach out of a plastic infusion bag. I attached it to a transfer set and it works perfectly. (group interview 2) The interviewees also mentioned visual instruction materials, such as texts, pictures, drawings, film clips and smartphone apps. They are particularly keen to have access to © 2016 John Wiley & Sons Ltd 1734 Journal of Clinical Nursing, 25, 1729–1739 M Bergjan and C Schaepe pictures and symbols, as they feel these resources are especially valuable: I think pictures, useful pictures, are ideal. Simple things with not much text. There’s too much text as it is. Patients are getting older and they struggle to read it. (group interview 3) Peritoneal dialysis trainers and patients are known to make and use their own written materials (e.g. translated instructions, memory aids and checklists). This indicates that written materials are better suited to revision and as a post-training refresher. Learning environment The interviewees said it was important for patients to train in conditions that are conducive to learning. Otherwise, they risk doing things incorrectly or acquiring bad habits. The PD nurses stressed that the training can occur entirely in the patient’s home, but that an alternative was to do a home visit on the last day of training. Given the many challenges associated with PD at home, the nurses said that at least part of the training should happen there: I think some training wouldn’t work out at all if it wasn’t done at home. The situation there is just so different: patients have to walk from the bathroom to the room where they do the PD. In a clinic or hospital, everything is within reach, everything you need is there. You’ve got enough light, there’s waste disposal (…). So sometimes you have to do one day at home (…) to make sure they can get their bearings. (group interview 2) Patients need help transitioning from the clinic to the home. They are likely to feel alone, overwhelmed and nervous, all of which might cause them to make mistakes. Also, questions usually start arising once the patient gets home. The interviewees therefore thought it was unfortunate that some nurses are either not allowed or not motivated to do home visits. Discussion This study aimed to explore PD nurses’ experiences, strategies and challenges with regard to the patient education process. The discussion will address the study quality and the most important findings. Non-professional actors Participants in our study state that a skilled PD trainer should be flexible and attentive to the individual needs of the patient and be willing to make joint decisions. However, we have to consider, that there are differences in patients’ and nurses’ perceptions of individualized care (Suhonen et al. 2012). The trainer must therefore be aware of the patient’s physical and mental condition and also their individual characteristics. Assessing PD patients in terms of their (re-)training needs seems to be a helpful tool and a starting point for identifying and closing knowledge gaps before a patient develops peritonitis (Russo et al. 2006). Thus, assessment skills are important for nurses involved in PD patient education. This is in line with the results of a current literature review (Blanch-Hartigan & Ruben 2013), which demonstrates that training a person’s perception accuracy can be effective. Perceiving patients’ states and traits and assessing their learning needs are therefore crucial tasks, a challenge for PD nurses and an important objective for their continuing education. Recommendations say that the principles of adult learning should form the basis of PD patient education (Hall et al. 2004, Bernardini et al. 2006, Finkelstein et al. 2011). Our findings illustrated the educational barriers that patients face, and this is consistent with the study by Clarkson and Robinson (2010). It is therefore worth discussing whether PD patient education should be solely based on adult learning theory. Its principles are certainly helpful, but its emphasis on self-directed learning might be too much of a challenge for CKD patients with cognitive, mental or physical impairments. Our results underline the term nosogogy, because the importance of tailoring the training to fit the individual patient must be taken into account, based on an assessment of his or her ability and readiness to learn (Ballerini & Paris 2006, 125). The subject the patient has to learn is not what he chooses to know as in andragogy. The patient needs to learn in order to perform the therapy in the most successful possible way (Ballerini & Paris 2006, 125). In contrary to healthy adults, PD patients are not completely independent. Participants provided valuable advice on training resources, such as the patient’s learning background and their relatives and peers. Peer support, which the interviewees felt was beneficial for the patients, is also used in other diseases. Peer support programs for people with cancer, for instance, have shown high levels of satisfaction but only mixed evidence of psychosocial benefit (Hoey et al. 2008). These schemes can also have negative effects, a fact that should be born in mind by those developing and implementing peer support programs (Embuldeniya et al. 2013). Objectives and content Acquiring psychomotor skills in general, and the ability to manage the bag exchange in particular, were the most © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1729–1739 1735 Original article Educational strategies and challenges in PD frequent answers given as to the overall objective of PD patient education. While the practical skills patients need to acquire obviously dominate training, interviewees also mentioned the cognitive and affective domains of learning. According to Hall et al. (2004), the cognitive domain includes memorization, concept formation, application of principles, making judgments and solving problems. Including these levels of learning within the cognitive domain is sure to improve patients’ knowledge and comprehension of PD therapy. The participants emphasized the need to alleviate fear at the start of training and to establish a collaborative relationship between learner and teacher within the affective domain of learning. Therefore, we believe PD nurses would benefit from training that helps them accurately perceive patients’ emotions, distress, pain and depression. This is recommended by Blanch-Hartigan and Ruben (2013). The interviewees stressed that the learner’s individual needs should guide the training content. PD nurses should be more sensitive to topics such as sexuality, which they do not usually bring up. This does not apply exclusively to PD patient training: in general, nurses do not actively address patients’ sexual concerns. Guidelines could be useful in helping nurses become more comfortable with actively addressing these issues. Peritoneal dialysis patient education goes beyond teaching patients how to change their bag safely and hygienically. Nephrology nursing has been criticized for teaching mainly technical skills and focusing on information about the loss of renal function. Our findings show that PD nurses emphasize that the acquisition of self-management skills is considered an additional objective of PD patient education. However, the topic did not dominate the interviews as much as the acquisition of psychomotor skills did. PD patients administer the majority of their care themselves at home (Hall et al. 2004) and have to make decisions about it every day. We therefore recommend promoting self-management skills in PD patients, as this has shown to improve their health (Su et al. 2009). In order to enable patients to self-manage their own care and consequently to become more autonomous and confident, sustained motivation is needed. Motivational interviewing principles and techniques can be used to promote patients’ engagement and empowerment (McCarley 2009) and are recommended for PD patient education (Gadola et al. 2013). Instructional materials and teaching activities Instructional materials are important for planning and providing patient education. The interviewees described creative ways of designing one’s own materials, which is as relevant as selecting and analyzing existing materials. Developing homemade materials is becoming increasingly popular in today’s multimedia world, but there are also benefits from using professional DVD’s, e.g. in pre-dialysis training (Chiou & Chung 2012). The importance of pictures and to simplify materials by reducing the amount of text they contain, has to be stressed. One probable reason for this is that many ERSD patients suffer from barriers to learning and are not receptive to large amounts of written information. Yost et al. (2013) also discusses the links between health literacy (HL) and indicators of cognitive impairment. The benefit of literacy-appropriate educational materials has been pointed out in the context of other chronic diseases (Wallace et al. 2009). Assessing and improving HL is a complex challenge and a general nursing task (Clement et al. 2009). Relationships have been found between communicative and critical health literacy (CCHL) and the self-management abilities of patients with CKD (Lai et al. 2013). Our findings do not indicate that nurses systematically assess their patients’ HL. While self-management is important in PD therapy, continuing PD nurse education must explain ways of measuring and assessing HL. HL awareness training, published by Mackert et al. (2011), could be helpful. Our findings show that PD nurses believe that teaching activities such as instruction and demonstration should be simple and concise. Where multiple trainers are involved, they should all give the same information so as to avoid confusing or overloading the patient. The teaching activities must also fit the patient’s individual learning and perceptual style. Page 629 of the ISPD guidelines gives an example of using a practice apron, where each step is described as it is performed (Bernardini et al. 2006). However, participants of this study recommend, that verbalization should be limited during psychomotor skills training, which is not supported in previous research. While there are certainly many technical aspects of the therapy to teach, it is important to remember that the learners are patients with a long term condition and need to have their social, emotional and psychological needs met. The interviewees mentioned problems with body image. A previous study (Partridge & Robertson 2011) found that levels of body-image disturbance correlated significantly with levels of anxiety and depression in adult dialysis patients. Participants in this study stressed the need to screen patients with CKD for signs of distress and bodyimage problems using e.g. the Kidney Disease Quality of Life Short Form (KDQOL-SFTM: Hays et al. 1997), the © 2016 John Wiley & Sons Ltd 1736 Journal of Clinical Nursing, 25, 1729–1739 M Bergjan and C Schaepe Body Image Disturbance Questionnaire (BIDQ: Cash et al. 2004) or the Hospital Anxiety and Depression Scale (HADS: Zigmond & Snaith 1983) and to offer targeted support. Our findings also show that there is a need for this kind of support. PD nurses could play a key role here by promoting cognitive-behavioral interventions for patients with body-image disturbances. Learning environment Patient questions about PD therapy often arise at home, which emphasizes the need for ongoing education and support. The participants of the present study highlight the importance of conducting home visits for assessment and training. This corresponds with previous research, which showed that home training achieved higher levels of patient, nurse and physician satisfaction (Castro et al. 2002). These findings underpin the ISPD’s opinion-based recommendation to use home visits as a way of gaining insight into how patients adapt and function in their own environment (Bernardini et al. 2006). Study quality The consolidated criteria for reporting qualitative research (COREQ) checklist guided the writing of the manuscript (Tong et al. 2007). One of the strengths is that the analysis was done deductively (theory-based main categories) and inductively (subcategories). Although the study did not include the patients’ perspective, it nevertheless gave insight into PD patient education by experienced PD trainers. The use of multiple trainer perspectives strengthened the understanding of PD patient education and provided information on the strategies used and challenges faced by PD nurses. While both authors have a nursing background, it is not specifically in nephrology. This meant they could bring an outsider’s perspective to their work and analyze the data from a mostly educational perspective. Several techniques helped maximize the trustworthiness of this study. To ensure inter-coder reliability, two coders each coded all the data material. Differences were resolved through discussion and the coders were able to reach full agreement. The interview guide was pilot-tested and the authors took notes, which added to the strength of the study. Study limitations included the lack of subject validation and the different sampling strategies. The group interview format could have influenced the findings as some interviewees might have been unwilling to raise teaching challenges in front of their colleagues. However, the participants knew each other and there was a good atmosphere. Conclusions and relevance to clinical practice While there is obviously a need for patients with a long term condition (LTC) to be involved in their care, there is an equally strong need for an individual PD patient training. The results of the current study provide some new insights into the best approaches to educating PD patients. Findings illustrate the educational challenges that patients face such as cognitive, mental or physical impairments. Further research might explore how nurses can help patients to meet these educational challenges. They highlight the importance to take in nosogogy, a special kind of adult education, because the importance of tailoring the training to fit the individual patient must be taken into account, based on an assessment of his or her ability and readiness to learn. Therefore the accurate use of assessment tools is crucial. Renal nurses have good experiences in developing literacy-appropriate educational materials together with their patients as in the context of other LTC. It could be recommended to undertake further research and to maintain this important educational strategy, but based on results of reliable health literacy assessments. There is also a need for screening for signs of distress and body image problems, in order to address affective learning objectives, e.g. addressing fears, improving body image and being more sensitive to topics such as sexuality. Consequently, this raises the notion of reconsidering instructional teaching activities and materials, and indicates that there are advantages to using experienced-based learning activities. PD nurses could play a key role by promoting cognitive-behavioral strategies for PD patients. Particularly, making use of motivational interviewing (MI) principles can promote PD patients’ engagement and support self-efficacy. MI principles such as expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacy can be integrated in care provision and training activities by the interprofessional team (Gadola et al. 2013). Even though psychomotor skills still overbalance PD patient training, additional effective training strategies would lead to improve the quality of PD patient education. Instruction and demonstration should be simple and concise. Moreover, it should be considered to review verbalization, as a common teaching strategy during psychomotor skills training in PD patient education. The mismatch between our findings and internationally accepted guidelines gives a reason for more research. Overall, our findings provide indications, that the theory of adult education is solely not sufficient for the © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1729–1739 1737 Original article Educational strategies and challenges in PD development of new teaching strategies and learning materials and for reflecting training situations with patients with chronic diseases. Because high flexibility and cooperation is needed in renal care, both, clinical and educational competence development should be promoted in continuing nursing education. Further research is needed to validate the findings and establish the patient’s perspective. Acknowledgements We thank Andreas Thorak (AT) and Manuela Kirstein (MK) for their valuable assistance with the analysis. Contributions Study concept and design: MB; developed the interview guide jointly: MB and CS; conducted the interviews: CS; data analysis: MB and CS (assisted by AT and MK) and wrote the manuscript and approved the final article: MB and CS. Funding This study received funding from Baxter Germany. The company played no role in the study design or in the collection and analysis of the data. References Baboolal K, McEwan P, Sondhi S, Spiewanowski P, Wechowski J & Wilson K (2008) The cost of renal dialysis in a UK setting – a multicentre study. Nephrology, Dialysis, Transplantation 23, 1982–1989. Ballerini L & Paris V (2006) Nosogogy: when the learner is a patient with chronic renal failure. Kidney International. Supplement 103, 122–126. Bastable SB (2003) Nurse as Educator. Principles of Teaching and Learning for Nursing Practice, 2nd edn. Jones and Bartlett Publishers, Mississauga, Canada. Bernardini J, Price V, Figueiredo A & International Society for Peritoneal Dialysis Nursing Liaison C (2006) Peritoneal dialysis patient training, 2006. Peritoneal Dialysis International 26, 625–632. Blanch-Hartigan D & Ruben MA (2013) Training clinicians to accurately perceive their patients: current state and future directions. Patient Education and Counseling 92, 328–336. Borras M, Sorolla C, Carrera D, Martin M, Villagrassa E & Fernandez E (2006) Patients with learning difficulties: outcome on peritoneal dialysis. Advances in Peritoneal Dialysis 22, 116–118. Cash TF. Body Image Assessments. Available at: http://www.body-images.com/ assessments/bidq.html (accessed 20 November 2015). Cash TF, Melnyk SE & Hrabosky JI (2004) The assessment of body image investment: an extensive revision of the Appearance Schemas Inventory. International Journal of Eating Disorders 35, 305–316. Castro MJ, Celadilla O, Munoz I, Martinez V, Minguez M, Auxiliadora Bajo M & del Peso G (2002) Home training experience in peritoneal dialysis patients. European Dialysis and Transplant Nurses Association, European Renal Care Association Journal 28, 36–39. Chiou CP & Chung YC (2012) Effectiveness of multimedia interactive patient education on knowledge, uncertainty and decision-making in patients with end-stage renal disease. Journal of Clinical Nursing 21, 1223–1231. Clarkson KA & Robinson K (2010) Life on dialysis: a lived experience. Nephrology Nursing Journal 37, 29–35. Clement S, Ibrahim S, Crichton N, Wolf M & Rowlands G (2009) Complex interventions to improve the health of people with limited literacy: a systematic review. Patient Education and Counseling 75, 340–351. Crowley ST (2003) CKD series: improving the timing and quality of predialysis care. Hospital Physician 39, 17–23. Curtin RB, Walters BAJ, Penell Ph, Wise M & Klicko K (2008) Self Efficacy and self-managment behaviours in patients with chronic kidney disease. Advances in Chronic Kidney Disease 15, 191–205. Embuldeniya G, Veinot P, Bell E, Bell M, Nyhof-Young J, Sale JE & Britten N (2013) The experience and impact of chronic disease peer support interventions: a qualitative synthesis. Patient Education and Counseling 92, 3–12. Fichtmuller F & Walter A (2007) € Pflegen lernen. Empirische Begriffs- und Theoriebestimmung zum Wirkgefuge von € Lernen und Lehren beruflichen Pflegehandelns. V&R unipress, Goettingen, Germany, pp. 659–667. Finkelstein FO, Ezekiel OO & Raducu R (2011) Development of a peritoneal dialysis program. Blood Purification 31, 121–124. Gadola L, Poggi C, Poggio M, Saez L, Ferrari A, Romero J, Fumero S, Ghelfi G, Chifflet L & Borges PL (2013) Using a multidisciplinary training program to reduce peritonitis in peritoneal dialysis patients. Peritoneal Dialysis International 33, 38–45. Graneheim UH & Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Hall G, Bogan A, Dreis S, Duffy A, Greene S, Kelley K, Lizak H, Nabut J, Schinker V & Schwartz N (2004) New directions in peritoneal dialysis patient training. Nephrology Nursing Journal 31, 149–154, 159–163. Hays RD, Kallich JD, Mapes DL, Coons SJ, Amin N, Carter WB & Kamberg C (1997) Kidney Disease Quality of Life Short Form (KDQOL-SFTM), Version 1.3: A Manual for Use and Scoring. Washington, DC: RAND, 1997[P7994]. Available at: http://www. © 2016 John Wiley & Sons Ltd 1738 Journal of Clinical Nursing, 25, 1729–1739 M Bergjan and C Schaepe rand.org/pubs/papers/P7994.html (accessed 20 November 2015). Hoey LM, Ieropoli SC, White VM & Jefford M (2008) Systematic review of peer-support programs for people with cancer. Patient Education and Counseling 70, 315–337. Kaptein AA, van Dijk S, Broadbent E, Falzon L, Thong M & Dekker FW (2010) Behavioural research in patients with end-stage renal disease: a review and research agenda. Patient Education and Counseling 81, 23–29. Kuckartz U (2014) Qualitative Text Analysis. A Guide to Methods, Practice and Using Software. Sage Publications, London, UK. Lai AY, Ishikawa H, Kiuchi T, Mooppil N & Griva K (2013) Communicative and critical health literacy, and selfmanagement behaviors in end-stage renal disease patients with diabetes on hemodialysis. Patient Education and Counseling 91, 221–227. Lameire N & Van Biesen W (2010) Epidemiology of peritoneal dialysis: a story of believers and nonbelievers. Nature Reviews Nephrology 6, 75–82. Mackert M, Ball J & Lopez N (2011) Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques. Patient Education and Counseling 85, e225– e228. Mason J, Khunti K, Stone M, Farooqi A & Carr S (2008) Educational interventions in kidney disease care: a systematic review of randomized trials. American Journal of Kidney Diseases 51, 933–951. McCarley P (2009) Patient empowerment and motivational interviewing: engaging patients to self-manage their own care. Nephrology Nursing Journal 36, 409–413. National Institute for Health and Care Excellence Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT. Available at: https://www.nice.org.uk/ guidance/cg125 (accessed 20 November 2015). Partridge KA & Robertson N (2011) Body-image disturbance in adult dialysis patients. Disability and Rehabilitation 33, 504–510. Paudel K, Namagondlu G, Samad N, McKitty K & Fan St L (2014) Lack of motivation: a new modifiable risk factor for peritonitis in patients undergoing peritonela dialysis. Journal of Renal Care 41, 33–42. Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye WC, Price V, Ramalakshmi S & Szeto CC (2011) ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Peritoneal Dialysis International 31, 614–630. Russo R, Manili L, Tiraboschi G, Amar K, De Luca M, Alberghini E, Ghiringhelli P, De Vecchi A, Porri MT, Marinangeli G, Rocca R, Paris V & Ballerini L (2006) Patient re-training in peritoneal dialysis: why and when it is needed. Kidney International. Supplement, 103, S127–S132. Schaepe C & Bergjan M (2015) Educational interventions in peritoneal dialysis: a narrative review of the literature. International Journal of Nursing Studies 52(4), 882–898. Su CY, Lu XH, Chen W & Wang T (2009) Promoting self-management improves the health status of patients having peritoneal dialysis. Journal of Advanced Nursing 65, 1381–1389. Suhonen R, Efstathiou G, Tsangari H, Jarosova D, Leino-Kilpi H, Patiraki E, Karlou C, Balogh Z & Papastavrou E (2012) Patients’ and nurses’ perceptions of individualised care: an international comparative study. Journal of Clinical Nursing 21, 1155–1167. Thomas N (2013) Renal Nursing, 4th edn. Wiley, Hoboken, NJ. Tong A, Sainsbury P & Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32- item checklist for interviews and focus groups. International Journal for Quality in Health Care 19, 349–357. Tong A, Lesmana B, Johnson DW, Wong G, Campell D & Craig JC (2013) The Perspectives of Adults Living With Peritoneal Dialysis: thematic Synthesis of Qualitative Studies. American Journal of Kidney Diseases 61, 873–888. Wallace AS, Seligman HK, Davis TC, Schillinger D, Arnold CL, Bryant-Shilliday B, Freburger JK & DeWalt DA (2009) Literacy-appropriate educational materials and brief counseling improve diabetes self-management. Patient Education and Counseling 75, 328–333. Watzlawick P, Beavin Bavelas J & Jackson D (1967) Pragmatics of Human Communication. A Study of Interactional Patterns, Pathologies and Paradoxes. W.W. Norton & Company, New York, London. World Medical Association (2013) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Journal of the American Medical Association 310, 2191–2194. Yost KJ, DeWalt DA, Lindquist LA & Hahn EA (2013) The association between health literacy and indicators of cognitive impairment in a diverse sample of primary care patients. Patient Education and Counseling 93, 319–326. Zigmond AS & Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatrica Scand. 67, 361–370. © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1729–1739 1739 Original article Educational strategies and challenges in PD |
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