Concise Appraisal of Qualitative Research Article

•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 conclusions

Remember 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 why

ORIGINAL 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.
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