QUANTITATIVE AND QUALITATIVE ARTICLE ANALYSIS
European Journal of Cardiovascular Nursing 2016, Vol. 15(7) 513 –521 © The European Society of Cardiology 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515115618569 cnu.sagepub.com
E U R O P E A N SOCIETY OF CARDIOLOGY ®
Introduction
An aging population and greater survival rates of patients with acute coronary events have increased the prevalence of individuals living with established coronary heart dis- ease (CHD) susceptible to recurrence.1 Evidence suggests that the disease process can be slowed or reversed through lifestyle changes.1,2 Despite this, several studies have reported poor disease-related knowledge in patients with CHD,3–5 that patients desire more information and support after discharge from the hospital6–8 and that they often fail to maintain lifestyle changes.9
European guidelines on cardiovascular disease preven- tion in clinical practice1 recommend health education
following discharge from the hospital to minimize adverse events. Patient education can increase knowledge and enhance behaviour changes10 and improve patients’
What is a good educator? A qualitative study on the perspective of individuals with coronary heart disease
Margrét H Svavarsdóttir1,2,3, Arun K Sigurdardottir3 and Aslak Steinsbekk1
Abstract Background: Patient views are especially important in patient education, as patient involvement is essential. However, no empirical research clarifies what knowledge, skills and competencies are needed for health professionals to competently serve as a good educator according to the patients themselves. Aim: To explore what qualities patients with coronary heart disease perceive in a good educator. Methods: A qualitative research method, with semi-structured individual interviews, was used in this study. Purposeful sampling was used to recruit participants from a general hospital in Iceland and in Norway. The data were analysed using systematic text condensation. Results: The participants included 17 patients who had been through a percutaneous coronary intervention and participated in formal patient education after discharge from hospital. The patients saw a good educator as one who they feel is trustworthy and who individualizes the education to patients’ needs and context and translates general information to their personal situation in lay language. Building trust was dependent on the patients’ perceiving the educator to be knowledgeable and good at connecting with the individual patient, so that the patients feel they are being treated as a whole person with equality and respect. Conclusions: The patients perceived the capability of building trust and tailoring the education to the individual as the most prominent characteristics of a good educator. Training skills that facilitate patients’ trust, being observant of the patient and his learning needs and adjusting the patient education to individual needs and situations should be key objectives in health professionals’ training in patient education.
Keywords Professional competence, coronary disease, health educators, patient education as topic, secondary prevention, trust
Date received: 9 August 2015; accepted: 27 October 2015
1 Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
2St Olavs Hospital, Trondheim University Hospital, Norway 3School of Health Sciences, University of Akureyri, Iceland
Corresponding author: Margrét Hrönn Svavarsdóttir, Department of Public Health and General Practice, NTNU, Postbox 8905 MTFS, 7491 Trondheim, Norway. Email: margret.svavarsdottir@ntnu.no; mhs@unak.is
618569CNU0010.1177/1474515115618569European Journal of Cardiovascular NursingSvavarsdóttir et al. research-article2015
Original Article
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health-related quality of life.11 Educating patients with CHD and their families is an integral component of sec- ondary prevention, in which health professionals play a key role. It is therefore essential that health professionals have the competence necessary to serve effectively as edu- cators for patients with CHD. Competence in patient edu- cation refers to proficient use of communication skills, such as the provision of information, advice and behaviour modification methods, to influence the patients’ knowl- edge, opinions, and health and illness behaviour.12 Yet, few studies13 have sought to show what competencies are needed to implement patient education for patients with CHD.
There is a growing recognition that health professionals can learn from patients, and the value of patient views is increasingly being recognized. Patient views are especially important in patient education, as patient involvement is essential. The value of utilizing the opinion of patients has been demonstrated in the development of patient educa- tional material,14 educational interventions15 and in some educational programmes the experiences of users are regarded as equally important as the contributions of the health professionals.16 Several studies have explored the educational needs and preferences of patients with CHD6– 8,17 and their disease experiences.18–20 Patients’ views on what competencies health professionals need to implement good patient education can help to determine the knowledge and skills needed to conduct effective education and can be used to improve health professionals’ competencies in creat- ing and implementing quality patient education. However, no empirical research clarifies what competencies a good educator needs according to the patients themselves.
The aim of this study was to explore what patients with CHD who have participated in patient education after a percutaneous coronary intervention (PCI) perceive as a good educator.
Methods
A qualitative research method with semi-structured face- to-face individual interviews was used in this study. This is an appropriate method of data collection when the enquir- ies relate to personal experience and perceptions21 and is thus well suited to provide an understanding of the issues of importance to patients.
Sample and recruitment
The aim was to recruit Icelandic and Norwegian individu- als with CHD who had undergone PCI less than 24 months earlier. Participants were required to have received formal patient education after their hospital stay, to be ⩾ 18 years of age and to be able to understand the study and study procedure. There were no further exclusion criteria. Participants were selected with purposeful sampling, to
ensure variation in age, gender and time since the PCI. To further increase the variation in the sample, patients from two countries were invited to participate. To recruit patients, nurses in one general hospital in Iceland and one in Norway introduced the study to eligible participants, handed out invitation letters and enrolled volunteers.
Data collection
The data were collected between June 2014 and May 2015. The interviews were conducted by the first author at a location chosen by the participants. The interviews were audiotaped and transcribed verbatim. The average inter- view duration was 44 min (range 17–69 min).
To ensure that all participants revealed their view on the same topic, an interview guide was used. The interview guide was developed by the first author with the help of a literature review, own insight and experience with the sub- ject, and a critical review and discussions with co-authors and a team of experienced researchers. The main question in the interviews was: Could you please describe your experience with patient education after your CHD inci- dent? The main question was followed up with open ques- tions about the participants’ experiences with patient education after the PCI, during and after their hospital stay, what they perceived as a good educator, what they appreci- ated the most in educators’ ‘performance’ and what they perceived as positive and negative aspects of the patient education they received.
The interview guide was revised after each interview and adjusted according to the themes that appeared in the previous interviews. Early in the data sampling, it became apparent that trust played a large role in the interviews, so a question about trust in patient education and what enhanced patient–provider trust was added. Other changes were minor and related to clarity of wording and sequence of questions.
Ethical considerations
The participants received written and oral information about the study, and they were informed that they could withdraw at any time and that confidentiality was assured. Written informed consent was obtained from participants before the interviews were conducted.
The study was conducted in accordance with the Helsinki declaration22 and was approved by the regional committee for medical research ethics in Norway (2014/947) and the ethics committee of Akureyri Hospital (3/2014) in Iceland.
Analysis
The data were analysed using systematic text condensation as described by Malterud.23 We began the iterative
Svavarsdóttir et al. 515
four-step process after the first interview by reading the transcribed interviews to obtain a general impression and identify preliminary themes. In the second step, we sys- tematically reviewed the transcriptions line by line, identi- fied the units of meaning, and classified and sorted them into themes. In the third step we sorted the units of mean- ing into subgroups and reduced the content into a distilla- tion of rephrased quotations, trying to maintain as much as possible of the original terminology used by the partici- pants. In the last step, we summarized the contents of each code group into generalized descriptions and concepts.
Analysis was carried out by the first author and dis- cussed and negotiated with the co-authors. To avoid pre- conceptions affecting the reflexivity of the results, we critically discussed the interpretation of the interviews between the co-authors and a team of experienced research- ers. Recruitment and interviewing of participants were continued until no new themes were found. The analysis was validated by reviewing the original transcripts of each interview to make sure that they were reflected in the results. The Icelandic and Norwegian citations were trans- lated into English by the first author and validated by co- authors. The citations that best illustrated the themes were chosen to illustrate the results. Those are marked with the participant’s sex, age, whether they underwent a primary (p-PCI) or elective PCI (e-PCI) and time from the PCI.
Results
Seventeen Icelandic and Norwegian patients with CHD, eight women and nine men, who had undergone PCI were
interviewed. The average length from the PCI was 6.5 months (1.5–19 months). Their average age was 59 years (range 47–72) (Table 1).
The findings were categorized into two themes that sum up the participants’ description of a good educator (Table 2). Trustworthy reflects the two main factors that contribute to the patients’ trust in the educator: that the educator is knowledgeable with professional credibility and is able to connect with the patients such that the patients feel treated as whole persons with equality and respect. The patients also wanted good educators to be able to individualize education to their individual needs and context.
Trustworthy
Knowledgeable. To trust the educators and be willing to follow their advice, the patients said that they needed to feel that the educators knew what they were talking about. This included the educator being confident and competent in explaining and answering questions. It was also beneficial if the information was congruent with what other health professionals had told them, and the patients’ prior knowledge or beliefs were also used to determine the educator’s reliability. If the patients suspected information to be based on convenience or personal opinions rather than scientific knowledge, they said they tended to lose faith in that educator. Speaking honestly about the patients’ situation and admitting a lack of knowledge also seemed to help in building trust.
What is important in all this is that they just say that they don’t know. Because, they don’t know. […] Then, you start trusting them. (Female <60, p-PCI 10 months earlier)
Which profession the educator belonged to was not impor- tant for most of the patients, but some said that they would trust cardiologists more as they thought they were more knowledgeable. Many of the patients said that knowing that the educator was specialized or worked in cardiac care made the educator more trustworthy.
I prefer education from a professional, for example a nurse, it doesn’t have to be a physician, he just needs to be professionally competent, be a specialist in the area he is educating about. (Female ⩾60, p-PCI 5 months earlier)
Connects with the individual. Most of the patients said that having a feeling of a personal connection with the educa- tors enhanced their trust in them. Expressions used were to show an interest in them, to listen to them and to consider the effect of the disease on their whole life and physical and mental well-being. A private chat, unrelated to their disease, was seen as an ice-breaker and as part of connect- ing with the educator.
Table 1. Demographic characteristics of the participants.
Number
Gender Female 8 Male 9 Age < 60 9 ⩾ 60 8 Nationality Norwegian 6 Icelandic 11 Education Elementary school or less 8 Vocational training or high school 6 College or university degree 3 Marital status Married 14 Widowed or divorced 3 Disease history Primary PCI 14 Elective PCI 3
PCI: percutaneous coronary intervention.
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They said they would be more relaxed and more recep- tive to information when they felt the educator was present and had time, was aware of what they had been going through, and treated them with respect and equality. This also helped the patients express themselves more freely and made them more comfortable to discuss and ask questions.
He talked over your head, but she talked with you. They really didn’t say different things, but she sat down, chatted about various things and then this [the patient education] came in between. It was kind of when you chat in your kitchen at home, you don’t get defensive or nervous. […] But he would stand at the end of the bed and talk down. […] She didn’t spend more time in talking to me, but her time was so much better. […] This was all so natural. It is this relaxed atmosphere. (Female <60, p-PCI 10 months earlier)
For some of the patients, being seen as a whole person included the educator seeing the family as a part of the picture, and they emphasized that the educator should be aware of the needs of their family or next of kin.
I feel badly about how uneasy this made my family, […] what they had to go through, they were much more anxious than I
was after the event. It is challenging to take care of the family. They were welcome to attend the patient education, which is very good, but they really need something [support], too. (Female <60, p-PCI 10 months earlier)
In contrast to educators who connected with them as indi- viduals, some patients described communication with edu- cators who did not listen to their views or respect their knowledge but used one-way communication to convince them to take actions they did not believe in. The patients said that this resulted in lost faith in those educators and that they became unreceptive to information from them.
Individualized education
The patients described having various educational needs, but a common theme for them all was the desire for more individualization. For example, having a health profes- sional sit down with them and translate general informa- tion to their personal situation in lay language. One example mentioned by several patients was how being shown graphical descriptions of their own coronary arter- ies with explanations of what had been done in their PCI
Table 2. Participants’ perceptions of the characteristics of a good educator.
Trustworthy Individualizes education
Knowledgeable Connects to the individual
Background in cardiology Specialized in cardiac care. Clinical experience in cardiac care.
Reliable information Confident in explaining and answering questions. Bases information on scientific knowledge. Information is congruent with information from other health professionals. Information is congruent with the patient’s prior knowledge.
Sees the whole picture Sees the patient as an individual. Considers physical and mental well-being. Includes the family.
Is present and has time Caring and friendly. Is interested in the patient and listens. Shows understanding.
Shows respect and equality Respects the patients’ views and wishes. Makes the patient feel comfortable to ask and discuss. Motivates the patient to ask and discuss. Is honest.
Invites information that benefits the patient Directs the patient in his knowledge seeking.
Tailors the education to individual needs and context Translates general information to the patient’s personal situation.
Explains and answers questions in lay language Adjusted to the patient’s level of understanding. Is clear and concise.
Selects the right time and condition for education Invites patient education when the patient is ready. Motivates. Ensures privacy.
Guides the patient Gives the patient a chance to decide when he so desires. Helps in decisions when the patient desires. Decides for the patient when so desired.
Svavarsdóttir et al. 517
helped them in understanding. The main topics they wanted individualized were their treatments and what had happened, why this had happened to them and how this all related to their symptoms.
You got some brochures with general information, but what you really needed was detailed information about what has been done [in the PCI] to you personally. […] What this all means for you. (Male <60, p-PCI 7 months earlier)
The topics the patients talked about in the interviews that they thought health professionals should be prepared to discuss and educate about are presented in Table 3. Some said that they did not know what knowledge would benefit them and were thus unable to ask or request information. They therefore appreciated it when the educator was aware of what knowledge would benefit them and could start the conversation about those issues and direct them in their knowledge seeking.
Another aspect of individualized education was that an educator must be capable of selecting the right timing and place for patient education. Many said they had limited benefits from the patient education they received during their hospital stay, as they were not in a state in which they were ready to receive information and remembered little of what was said. All of the patients expressed a need for more patient education after discharge from the hospital, and many emphasized the need for the repetition of infor- mation. Some patients gave examples of a lack of privacy hindering them in asking, sharing or discussing informa- tion during the hospital stay. Other patients talked about their experience of having difficulty asking questions in a group because they did not have the courage to speak out in public or did not want to appear stupid.
You get a lot of information when you are discharged, but you just don’t get it all. […] What would be better is an interview shortly after discharge. […] It is this follow-up that is needed. (Male <60, p-PCI 7 months earlier)
Most of the patients emphasized the importance of being in control but expected the educators to guide them in their choices. However, when realizing that they did not make a good choice or had failed to follow advice, some of the patients said that the educator should have tried to per- suade them otherwise or been stricter. The patients also gave examples of instances where they felt that the educa- tor should make decisions for them or take control, for example, when they felt their condition was too serious, or when they felt that they did not have sufficient knowledge to make the decision themselves.
They explained to me how big of a risk factor this is [the smoking]. […], but they all talked very mildly about this […] they could have said this in a more determined way, more harsh. (Male ⩾60, p-PCI 7.5 months earlier)
Discussion
The participants saw a good educator as one who is trust- worthy and able to individualize the education to the patients’ needs and context. Building trust was dependent on the patients’ perceiving the educator to be knowledge- able and good at connecting with the individual patient by using communication skills that made the patients feel seen, heard and respected.
Promoting trust in the patient–educator relationship
The central finding in this study was that the participants consider being trustworthy the most essential characteris- tic of a good educator. To our knowledge, no empirical study has described the importance of trust in patient edu- cation or the factors that promote trusting patient–educator relationships from the patients’ perspective.
However, trust has been described as essential in the development of the nurse–patient relationship24 and has been associated with successful lifestyle changes,25 adher- ence to medication and treatment plans,26 preference for involvement in medical care27 and perceived control over the disease.28 It has been stated that promoting trust is a demonstration of the provider’s ability to show interper- sonal and technical competence, moral comportment and vigilance to support positive patient outcomes.29 Thus, in concordance with the patients’ perspective, knowledge and competency in skills that facilitate a trusting patient–pro- vider relationship are important for educators.
There are, nevertheless, some negative aspects of a trusting patient–provider relationship that the educator should be aware of. In contrast with our findings, patients’ trust in others has also been associated with patients being less active and less motivated to improve their health situ- ation.30 There might also be differences in level of trust between groups of patients, with studies suggesting that the elderly and less educated cardiac patients are more trusting,28 and one study showed that cardiac patients with less health literacy were more distrusting of their physician.31
In this study, patients’ perceptions of the educators’ knowledge had a strong influence on their trust in the edu- cator. Knowledge is a basic competency in patient educa- tion13 and has been found to be necessary for the development of a professional relationship and building trust between health professionals and patients.32–34 In line with our results, others have found that to be successful in lifestyle counselling, health professionals need to have experience and good knowledge of the subject,13,33 give a credible impression33 and exhibit their competence and knowledge to the patients.32 This can be the reason why the patients in this study wanted education from health professionals that specialized in cardiac care and had
518 European Journal of Cardiovascular Nursing 15(7)
worked with cardiac patients, as they felt these characteris- tics made educators more knowledgeable and more likely to have a nuanced understanding of a patient’s situation. This is also supported by the findings of a previous study that demonstrated that cardiac patients have a high degree of trust in their cardiologist,28 and their preferred source of heart disease information and lifestyle change support was the cardiac rehabilitation staff.17 Patients’ perspectives are increasingly being incorporated into learning programmes and patients are used as educators for other patients.16 The patients in this study preferred patient education from a health professional specialized in cardiac care. This indi- cates that when organizing patient education, health profes- sionals should take an active part themselves and not, for example, leave patient education to only lay educators.
The other factor contributing to trustworthiness from the patients’ perspective was how the educator managed
to connect with the patient and the use of communication skills that made the patients feel seen, heard and respected. Educators themselves have also acknowledged that the capability to connect with patients is a basic competency in patient education.13 Connecting with the educator was said to enable free and relaxed expression. This could help the educator in tailoring the education to individual needs. Building trust is considered a dynamic process,29 and taking time with the patient and continuity of care is needed to develop trusting relationships.29,33 Similarly, our results indicate that continuity of care and repeated interactions are needed to promote a trusting patient– educator relationship.
As patients perceive building trust as an essential characteristic of a good educator, skills that promote trust should be a key objective in health professionals’ training in patient education. However, in a systematic review, it
Table 3. The topics that the patients wanted educators to be prepared to discuss and provide education about.
Topic Quotes
The heart Overview of the heart and the vascular system. […] understand how the body works, then it will be easier to change. (M ⩾60, p-PCI 4 months earlier)
The disease He explained the disease to me and then I felt relived. (M ⩾60, e-PCI 7.5 months earlier)
Cause Why me, what caused this.” (F ⩾60, p-PCI 5.5 months earlier)
Reflection of the incidence I needed someone to sit down with me and talk to me about what I had been through. (F <60, p-PCI 3.5 months earlier)
The PCI To visually see this at the same time he was explaining […]. I found it very helpful […] to see how my coronary arteries were before and after. (M <60, p-PCI 10 months earlier)
Medication I had those two pills, I figured that one of them must be temporary and stopped taking the one prescribed later, and then I got a chest pain. (M ⩾60, p-PCI 7 months earlier)
Symptoms It explained a lot for me, why I had so little energy at work and to walk, and the pain in the breastbone that had been a mystery to me. (M ⩾60, e-PCI 19 months earlier)
Seriousness Many of them were allowed to drive a car much earlier than I was, and thus, I just assumed that this must have been very serious. (M ⩾60, p-PCI 4 months earlier)
Recovery Some have full recovery, and others don’t. […] What chances do you have to go back to normal life […] Will I be able to go back to work? (F ⩾60, p-PCI 5.5 months earlier)
Consequences There should be more information about the consequences. It is not the end […], you can live with it, you can have an all right life. (F ⩾60, p-PCI 5.5 months earlier)
Dos and don’ts You need to know what to be careful with and what is safe to do. (F ⩾60, p-PCI 5.5 months earlier)
Recurrence If this will happen again, what then? Maybe it will be very serious and I will be unable to call for help. (M ⩾60, p-PCI 10.5 months earlier)
Available treatment To know that if the stent, or whatever this is, fails and you get another occlusion, then this could be performed again, meant a lot to me. (M ⩾60, e-PCI 19 months earlier)
Comorbidities That this was not something I was magnifying, worries or stress, but something that follows the disease process when you get severely ill. (F <60, p-PCI 10 months earlier)
Stress/emotional reactions Sometimes you need encouragement. […] This is a serious disease and it is very helpful to be able to express yourself and talk about how you feel. (F <60, p-PCI 9 months earlier)
How to enhance recovery To tell me how important the physiotherapy is […] Then, I would have made other decisions. (F <60, p-PCI 3.5 months earlier)
Available services There are social workers and psychologists, but people don’t know where to go. It needs to be included in this education where you can get help. (F ⩾60, p-PCI 5.5 months earlier)
Risk factors They constantly repeat that you should go out for a walk. Maybe you are too lazy to go out for a walk. We need more education about how important this is. (F ⩾60, p-PCI 5.5 months earlier)
M: male; F: female; p-PCI: primary percutaneous coronary intervention; e-PCI: elective percutaneous coronary intervention.
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was found that efficient interventions to develop skills in promoting trust are lacking.35 There is thus a need for developing approaches to efficiently train educators in the type of skills and knowledge needed to gain the patients’ trust.
Tailoring the education to the individual needs and context
It is known that tailored face-to-face communication is an effective method for creating behaviour change in patients.36 The patients in this study, in concordance with previous research,7,8 favoured a verbal face-to-face approach, as this enabled them to ask questions and obtain further explanations and provided an opportunity for dis- cussion about their personal situation. To facilitate changes in the patient’s lifestyle the educator needs to be able to understand the patient’s everyday life and to identify motives for change.33 Our results indicate that although for practical reasons patient education needs to be delivered in group settings, there are patients who want to be offered private consultations. Decreasing length of hospital stays37 and a busy clinical environment38 pose a special challenge to patient education, and tailoring the education to each patient’s individual needs and context can become difficult to implement. Thus, a good educator is dependent on a sys- tem that allows for time and space within their clinical work to do so. One solution might be a nurse-managed clinic where the patient is in a follow-up programme inte- grating education after a hospital stay.39–41 This is espe- cially relevant as it has been found that trust scores are higher for patients in nurse-managed clinics than joint- managed clinics,29 they are more effective than standard care in reducing cardiovascular risks and improving patient lifestyles,39–41 and they can have an effect on psychologi- cal well-being.42
Strengths and limitations
This study was undertaken among a specific group of patients (patients with CHD), which might limit the gener- alizability of the results to other patient populations. However, we had good variability within the sample as the study was performed in two countries, included both patients that had been through a p-PCI and patients that had been through an e-PCI, the patients were treated at four different treatment centres and had gone through two different educational programmes. There was also good variability in the time from event to the interviews; hence, the results reflect the patients’ view in the first 19 months of the disease process. Given this and that the results of this study demonstrate a diversity of patient preferences that are supported by research in other areas, we argue that the findings are likely to be transferable beyond the current context.
The major limitation of the study is that it does not distinguish between competencies needed for different educational methods such as group or individual education, or contexts such as education within hospitals or after dis- charge or at various times from the event. As the partici- pants were recruited by nurses from the patient educational programmes in which the patients had participated, we may have missed some criticism or negative perspectives.
Conclusions
The results provide an understanding of factors that pro- mote trusting patient–educator relationships and comple- ment the competencies of the educator, from the patient perspective. The patients in this study wanted patient edu- cation from a health professional specialized in cardiac care and preferred individual face-to-face patient educa- tion. Building trust and the capability of tailoring the edu- cation to individual needs and contexts were identified by the participants in this study as the most prominent charac- teristics of a good educator.
Implications for practice
•• To be trustworthy is a characteristic of a good educator;
•• Educators must be able to connect and build trust; •• Educators must be observant of the patients and
their learning needs; •• Educators must be competent in tailoring the
education to the individual; •• Educators must treat the patient with equality
and respect.
Acknowledgements
We thank the patients who generously gave their time and shared their experiences. We also thank the nurses who assisted in the recruitment of participants.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This work was supported by the Central Norway Regional Health Authority.
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