Number of Pages: 2 (Double Spaced)

Number of sources: 4

Writing Style: APA

Type of document: Article

Academic Level:Undergraduate

Category: Nursing

Language Style: English (U.S.)

Order Instructions: Attached

Write a summary and concise appraisal of the study. Use the APA format with title page, 3-4 paragraphs for summary and critique (300-400 words), and the complete reference at the end. Utilize Chapter 14 in your Fain, (2017), book as your guide Concise Appraisal of Qualitative Research Article.

First Paragraph: Write a brief description or summary of the work cited including:

•the level of research evidence (based on Melnyk and Fineout- Overholt’s Level of Evidence Scale in Module 1 under Dr. Poole’s video link)

•purpose

•type of qualitative study

•major findings or themes

•author’s 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 Concise Appraisal of Qualitative Research Article.

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, Charit e –

Universitaetsmedizin Berlin, Berlin; Christiane Schaepe, RN, MPH,

Research associate, Institute of Health and Nursing Science,

Charit e – Universitaetsmedizin Berlin, Berlin, Germany

Correspondence: Christiane Schaepe, Research associate, Institute

of Health and Nursing Science, Charit e – 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 Concise Appraisal of Qualitative Research Article.

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) Concise Appraisal of Qualitative Research Article.

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) Concise Appraisal of Qualitative Research Article.

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 Concise Appraisal of Qualitative Research Article

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 Concise Appraisal of Qualitative Research Article. 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: Concise Appraisal of Qualitative Research Article

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 Concise Appraisal of Qualitative Research Article

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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