EBP presentation

Technology versus Tradition:An Evidence Based Project about the efficacy of teaching methods

Alyssa Barton

Heather Foreman

Jessica McCoy

Allison Rodgers

Alvernia University

Mission Statement

PICO QuestionIn hospitalized clients with heart failure, what is the effect of computer-

based instructional methods, compared to written and verbal instructional methods, on client understanding of heart failure treatment?

Weighing-InLearning Objectives

• The learner will identify appropriate teaching strategies and their benefits.

• The learner will identify barriers to effective client teaching.

• The learner will recognize their own level of knowledge on heart failure and assess their level of comfort with teaching clients.

• The learner will identify recommendations for future teaching interventions and how they could improve their own current teaching method.

Round 1: The Clinical Significance

• In 2010, there were 1 million hospital related admissions from Heart Failure in the United States (Carr, McDermott, Tadbiri, Uebbing, & Londrigan, 2014).

– 25% of those clients were readmitted within 30 days of discharge.

• Readmission is typically due to non-adherence and insufficient knowledge of medications, diet, and identifying symptoms (Dilles, Heymans, Martin, Droogne, Denhaerynck, & De Geest, 2011).

• In 2012, Medicare decreased hospital reimbursement for readmitted clients (Carr, et al., 2014).

• Healthy People 2020- Reduce Heart Failure readmission rates (Carr, et al., 2014).

• St. Joseph’s currently utilizes a combination of verbal and written teaching based on current American Heart Association guidelines.

• Other hospitals in the area have different approaches:

– Reading Hospital: Interactive Computer Based Learning

– Good Samaritan: Heart Failure Coordinator

Round 2:The Current Practice

Current Hospital Handouts for Heart Failure

Standard Practice• Standard care brochures

covering 10 topics:– Cause, diagnosis, treatment,

medications, healthy lifestyle, alarm signals, vaccinations, driving/holiday travel, infection prevention, diary/journal

Computer Assisted Learning• Computer assisted learning

with standard includes CD-ROM interactive program:– Circulatory system, heart

failure symptoms, diagnosis, medications, self-care, and self test for review.

Round 3:Definitions

Round 4: Literature Review

• Initial research led to 12 primary articles:

– Narrowed down to 9 with the strongest design and purpose for the basis of this research project.

• Years searched: 2000 – 2015

• Databases searched: Health EBSCOhost, Johanna Briggs Institute, CINAHL, Cochrane Library, Medline, Google Scholar

– Articles acquired from Health EBSCOhost, Johanna Briggs Institute, and Google Scholar

• Levels of evidence in articles selected:

– Level I: Systematic Review

– Level II: Randomized Control Trial

– Level III: Quasi-experimental

– Level IV: Case Control/Cohort Study

– Level VII: Expert Opinion

• Key Words: Computer, Written, Verbal, Nurse Teaching, Heart Failure, Older Adults,

Round 5:Considerations

• There is no minimum time requirement for discharge teaching, therefore not every client in the hospital may get adequate and thorough information (Albert, 2013).

• Consider age and cognition status of the client.– Not understanding older adults and their learning preferences is

a barrier to teaching (Nevins, n.d.).

– There are many different methods to teaching: auditory, visual, and written.

• Hospital Budget and Location– Population Demographics

• Only 11% of lecture is retained in long term memory (Nevins, n.d.).

– 83% of adults are visual learners, 11% are primarily listeners (auditory).

• Previous RCT in Sweden concluded greater knowledge retention using computer assisted learning (CAL). A replicated study in Belgium concluded no significant difference between knowledge and self-care retention between a standard group using written and verbal materials with those using a CAL program (Dilles, et al., 2011).

– CAL advantages: » Requires active participation, family able to utilize information from

CD-ROM, clients control the flow rate of the information, visual aids for those who are not comfortable with text and auditory learning.

– CAL disadvantages:

» Lack of personal interaction between nurse and client and difference in comfort with technology for the older adult.

Round 6: Summary: Results

• Cost of computer programs may not be as effective in the end result (Ågren, Evangelista, Davidson, & Strömberg, 2013 ).

– RCT conclusion of control group with standard care against intervention group given computer based learning program showed no significant difference between clients. Both had increase in knowledge scores and increase in overall health.

• Use of client centered material (larger font, shorter explanations, individually tailored to client) were better recalled and understood than standard pharmacy brochure formats (Marrow, Weiner, MD,, Young, Steinley, Deer, Murray, 2005)

» Standard Care Client Recall 60%» Client Centered Care Recall 64%


• Study completed with experimental group given DVD and stand alone booklets against control group given written instructions yielded no statistically significant results on health status, but had a positive impact on self-care behaviors. (Veroff, Sullivan, Shoptaw, Venator, Ochoa-Arveola, Baxter, Manocchia, & Wennberg, 2012).

– Daily Weight» 44% Experimental» 37% Control

– Fluid Intake» 47% Experimental» 44% Control

– Low Sodium Diet» 83% Experimental» 77% Control

– Physical Activity» 38% Experimental» 44% Control


• Adult learners prefer self-direction with learning (Nevins, n.d.).

– Want to learn only what they need to know.– Attach meaning to learning based on life experiences.– Prefer practical approaches with hands-on activities

• Problem solving activities, self-care diaries, etc.• More receptive when it’s exciting.

Round 7: Summary: Teaching Strategies

• Measure knowledge and self-behavior teaching efficacy with tools (Carr, et al., 2014).

– Knowledge Tools: • Atlanta Heart Failure Knowledge Test

– 30 question Multiple Choice Assessment Tool to measure knowledge retention

• Dutch Heart Failure Scale

– Self-Care Behavior Tools:• European Heart Failure Self-Care

Behavior Scale

• Self-Care Heart Failure Index– 22 questions on the client’s

confidence with self-care

behaviors for heart failure.


• Addition of illustrations in teaching can improve comprehension and retention of information (Carr, et al, 2014).

– Illustrations enhance client understanding of written material (Friedman, Cosby, Boyko, Hatton-Bauer, & Turnbull, 2009)


• Use of cognitive-behavioral strategies improve self-care in clients with heart failure in reducing complications (Barnason, Zimmerman, & Young, 2011).

–Teach-back


• Assess knowledge, learning abilities, learning styles, cognition and motivation of client prior to attempting heart failure teaching (Paul, 2008).

– Cognition: do they have a readiness to learn?

– Learning Styles: Auditory, Visual, Text learner?

– Motivation: Were they given bad news? Are they tired? In pain?

– Learning abilities: Can you determine their reading comprehension level?


• Culturally appropriate education increases client knowledge (Friedman, et al, 2009).

• Verbal teaching and discussion as stand-alone methods are the least effective strategies.

• There is no “one-size fits all” solution for teaching clients in the hospital (Friedman, et al., 2009).

• Readiness to learn, cognition levels, distractions are all items that effect retention of discharge teaching.

Round 9:Summary: Barriers to Teaching

Round 10:Summary: Nursing Knowledge & Preparation

• Nurses are comfortable in cardiovascular knowledge but uncomfortable and inadequately prepared as heart failure educators (Albert, 2013).

– Not every nurse has same level of training in cardiac issues.– Time constraints on nursing discharge teaching may limit the

amount of time they spend with each client going over material.– They may or may not assess learning effectiveness after

teaching.

Round 11: The Final CountdownRecommendations: K-I-S-S

• Re-evaluate computer assisted learning efficacy within 10 years as the technology generation begins to age.– Can still utilize computer assisted learning on request or as a supplemental

guide.• As a supplement agent, it can reduce necessary time the nurse needs to spend re-reviewing

material.

• Incorporate a combination of visual, auditory

and text learning materials.– Knowledge and Self-Care Behavioral

Assessment Evaluations– Use teach-back to measure efficiency of education

• Have the client teach you.

Round 11: The Final CountdownRecommendations: K-I-S-S

• Lower the level of literacy education materials.– Also account for visual, hearing, and cognitive changes in the older adult by reducing noise

distractions and using large print materials.

• Individualized client centered teaching with involvement of family or support system.

– First assess their current knowledge of their disease and then reinforce areas they are not as sufficient in.

• Include nationally recognized material (American Heart Association)

• Take into effect culture, language, and learning environment.– Someone who speaks another language may not be able to read in that particular language.

Round 11: The Final CountdownHulk Smash!

• It’s all about what the client wants!– Computer learning may be effective for some

generations but may cause stress to others. – Teaching methods are as individualized as the

information you are presenting to the client.

• Be creative! – Keep the client intrigued and actively participating

ReferencesAgren, S., S Evangelista, L., Davidson, T., Stromberg, A. (2013). Cost-effectiveness of a nurse-

led education and psychosocial programme for patients with chronic heart failure and their

partners. Journal of Clincial Nursing, 22(15/16), 2347-2353. doi:10.1111/j.1365-

2702.2012.04246.x

Albert, N. M. (2013). Parallel paths to improve heart failure outcomes: Evidence

matters. American Journal Of Critical Care, 22(4), 289-297. doi:10.4037/ajcc2013212

Barnason, S., Zimmerman, L., & Young, L. (2012). An integrative review of interventions

promoting self-care of patients with heart failure. Journal of Clinical Nursing, 21(3/4), 448-

475. doi:10.1111/j.1365-2702.2011.03907.x

ReferencesCarr, H.J., McDermott, A., Tadbiri, H., Uebbing, A., & Londrigan, M. (2014). The effectiveness of computer-

based learning in hospitalized adults with heart failure on knowledge, re-admission, self-care, quality of

life and patient satisfaction: a systematic review. JBI Database of Systematic Reviews & Implementation

Reports, 12(5), 430-465. doi:10.11124/jbisrir-2014-1430

Dilles, A., Heymans, V., Martin, S., Droogné, W., Denhaerynck, K., & De Geest, S. (2011). Comparison of a

computer assisted learning program to standard education tools in hospitalized heart failure

patients. European Journal Of Cardiovascular Nursing, 10(3), 187-193.

doi:10.1016/j.ejcnurse.2010.07.001

Friedman, A. J., Cosby, R., Boyko, S., Hatton-Bauer, J., & Turnbull, G. (2011). Effective teaching strategies

and methods of delivery for patient education: a systematic review and practice guideline

recommendations. Journal Of Cancer Education, 26(1), 12-21. doi:10.1007/s13187-010-0183

ReferencesMorrow, D. G., Weiner, M., Young, J., Steinley, D., Deer, M., & Murray, M. D. (2005). Improving medication

knowledge among older adults with heart failure: A patient-centered approach to instruction design.

Gerontologist, 45(4), 545-552.

Nevins, A. (n.d). Teaching the older adult [PDF document]. Lecture Notes Online Web

site: http://www.hartfordign.org/

Paul, S. (2008). Hospital discharge education for patients with heart failure: What really works and what is the

evidence?. Critical Care Nurse, 28(2), 66 – 80.

Veroff, D. R., Sullivan, L. A., Shoptaw, E., Venator, B., Ochoa-Arvelo, T., Baxter, J. R., & Manocchia, M., Wennberg,

D. (2012). Improving self-care for heart failure for seniors: The impact of video and written education and

decision aids. Population Health Management, 15(1), 37-45. doi:10.1089/pop.2011.0019

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