Nancy Albert, Ph.D., R.N., is Director of Nursing Research and Innovation in the Division of Nursing and Clinical Nurse Specialist at the Kaufman Center for Heart Failure at Cleveland Clinic. We will discuss her study, Randomized study of the effect of video education on heart failure healthcare utilization, symptoms, and self-care behaviors, which she completed in 2007.

Patient Education Update: Why do a study of heart failure patients using patient education resources at home?

Albert: The Joint Commission and other quality monitoring groups believe strongly that education is an important component before hospital discharge. But nurses don’t always have the time to do a thorough job of educating patients. So the patients may suffer in that they are not getting the information they need to live a better lifestyle when they get home.

PEU: Why video programs?

Albert: My hope was that video education, in addition to verbal one-on-one education that nurses would give, would provide a visual resource for patients that’s different than just getting a written handout. Because the resource offers demonstrations, repeats messages they can view more than one time, and shows real life people just like them carrying out actions, it would help increase a patient’s confidence in being able to carry out lifestyle behaviors. I also thought it could help their family members who weren’t present at the time that the education was given in the hospital. We learned that 56% of the patients watched the video with family or friends.

PEU: What results were you looking for?

Albert: My hope was that it would actually improve patient outcomes, meaning survival, although this study was not powered for survival. We were really looking at hospitalization rates and adherence to therapy.

PEU: What did you learn about video as an educational tool?

Albert: The whole point of video education is that it’s just like watching a TV commercial. We chose to add some “commercials,” for lack of a better term, between chapters since this video was an hour long. These “commercials” covered weighing and monitoring yourself and those were the areas where patients did best in the outcomes of my study.

PEU: Were patients cooperative?

Albert: Well, eight patients or 22% failed to watch the video. Now, you are always going to have some people on that side of the bell curve even though we knew they all had video equipment.

PEU: What did the patients think of the video?

Albert: In general, when we asked if the information in the video was easy to understand, 71% said yes. They responded strongly or fully agreed with that. Another high ranking question was if they would recommend this video to other people with heart failure. 89% said either they strongly agreed or fully agreed with that.

PEU: Over a 3 month period, it didn’t statistically reduce hospitalizations, but what were the benefits you saw?

Albert: The benefits were really about patients having a better understanding of their condition and learning how to monitor themselves, so that they could not only conduct self-care maintenance behaviors but also start carrying out management care behaviors.

PEU: Why is that significant?

Albert: We define self-care maintenance as doing what you are asked to do such as exercising regularly, weighing yourself, or following a low sodium diet. But self-care management is a different concept, taking an assertive or aggressive step in getting yourself out of trouble when something isn’t right. An example of self-care management for a heart failure patient would be cutting back on the sodium in their diet because they noticed that their weight went up, or that their ankles were swollen in the morning. It may be someone changing their fluid restriction of 8 cups a day to 6 cups a day for 2 or 3 days while they’re trying to overcome feeling more fatigued.

PEU: So their self-care management skills improved?

Albert: Yes, either improved or they realized that they had control. Maybe prior to that they didn’t think they had any control, so their focus would have been to go back to the hospital or their doctor, or wait until they were miserable or ending up in the emergency room.

PEU: Were there statistical differences in self-care management skills?

Albert: Here’s one of the things we noticed for people who said they noticed swelling. We asked them if they changed their diet to reduce sodium. That was significantly better statistically in the video education arm than in the control arm (patients with no video education). Another example was if they decreased their fluid intake if they felt fatigued. Again, it was significantly better statistically in the video education arm than in the control arm. A third example was whether they took an extra diuretic or water pill if they had gained weight? Again, this significantly improved statistically in the video arm than in the control arm.

PEU: How important is the role modeling that patients see in the videos?

Albert: To me it’s very important, and one of the benefits of video education. Many times patients with heart failure, even if they hear the message, are afraid to do something because of threats to their health or an ingrained fear to openly discuss things with their health care provider. But if they see someone else on a video that kind of looks like them, has gray hair, and looks elderly doing something they were asked to do, it may help make it more feasible for them to carry that out themselves.

PEU: Typically, heart failure is seen in older people, traditionally less technically savvy than younger people. Was that an issue?

Albert: It was a slight issue but not a big issue. First of all, we are a transplant hospital so we tend to get younger patients. In fact, our mean age was under 65 and we did have older as well as younger people. If I was in a community hospital, that could have been an issue. We are noticing an increase in usage of information technology by our elderly, in general. I have some patients, and these are all elderly gentlemen, who send me emails telling me that they’re not feeling well. But my mother doesn’t want a computer even though we tried to buy her one. It’s very variable.

PEU: Were there any big surprises?

Albert: We were working with VHS just when DVD was starting to become popular. We had a hard time enrolling patients and we didn’t expect that. That swing to DVD happened very fast and many people had gotten rid of their VHS players.  If we were fully into the DVDs, we would have absolutely been able to get more people for the study.

 

For an abstract of the study, go to Randomized study of the effect of video education on heart failure healthcare utilization, symptoms, and self-care behaviors.