In the CR population, it has been reported that some patients understand little of what has happened to them or how to manage their lives in the aftermath of their treatments [6
]. Unfortunately, some patients also report that they would want and need more information than they usually receive in the course of CR [5
]. In order to plan and deliver an effective CR educational intervention, it is important to have precise information about the educational needs of the patients (i.e. how patients want their education to be) [40
Indeed, the literature highlights the importance of a comprehensive understanding of patients’ health information needs as one of the first steps in developing educational curriculums [20
]. The needs analysis as part of our curriculum development process included the five steps described below.
Development of a tool to assess CR patient information needs:
Despite the fact that there are studies assessing information needs of patients following revascularization [41
], acute coronary syndrome [43
], and myocardial infarction [45
] to our knowledge, there were no validated tools to assess educational needs in CR patients. Therefore, we developed and psychometrically
validated a tool to assess information needs in CR patients, called INCR (Information Needs in CR) [59
]. The INCR Tool was demonstrated to have good reliability and validity. It was considered an appropriate tool for application in clinical and research settings, assessing patients’ needs during CR and as part of education programming [59
Assessment of CR patients’ information needs and CR clinical staff awareness of patients’ information needs:
In a cross-sectional study, 306 CR patients and 28 CR providers completed a survey in order to investigate CR patients’ information needs, whether CR providers are cognizant of patient’s information needs and preferred delivery formats, and whether patient information needs change over the course of CR. The survey consisted of the INCR tool, and questions about preferred education delivery formats [60
Both patients and CR providers generally reported all 55 informational items as “important” to learn, suggesting that CR, which affords repeated contacts over time between patients and providers, must play an important role in ensuring all patients’ information needs are met. The greatest information needs identified by patients were related to medication, emergency/safety, and diagnosis and treatment, and were perceived as stress/psychological factors, emergency/safety, and risk factors
by CR providers. CR providers were quite aware of patients’ information needs, except in regard to diagnosis and treatment. Finally, most additional questions CR providers reported they received by patients are included in the INCR tool, supporting its validity and comprehensiveness [59
Overall, patient’s desired information in areas that are vital to patient survival and on-going control of symptoms, were congruent with what CR providers were teaching. In this study, there was agreement between patients and CR providers that emergency/safety was one of the highest information needs, an important result that influenced the development of the educational curriculum. Moreover, in contrast to other studies [43
] patients identified ‘risk factors’ as one of their lowest information needs. Finally, providers should focus on educating patients of lower income, as they identified significantly greater educational needs than their high income counterparts [63
In regards to delivery formats, lectures, books and discussions with healthcare providers were identified as the preferred formats by patients, and were also aligned with what CR providers perceived as patients’ preference. Surprisingly, patients did not desire to learn through electronic media resources such as the internet and e-learning. Despite patients’ preferences for non-electronic resources, the effectiveness of this type of technology in patient education has been described in the literature [64
Environmental scan of other CR programs:
In order to understand how education is delivered in similar CR programs, an environmental scan was performed. From 12 possible sources for this scan, 3 (25%) responded. Together, the programs provide a variety of education topics including exercise, medical, risk factor identification and modification and goal setting. Group and individual education is offered as well as workshops in smoking cessation, stress and weight management. Two of the CR programs involve patients in the process of developing the curriculum for their education program (via feedback surveys). A patient needs assessment done in one cardiac rehab program
resulted in their team revamping the content, amount of detail and comprehension level of the education offered to their patients and family. Modes of delivery consist of power point presentations, hand-outs, workbook and e-learning (for those with internet access). Nutrition education includes use of food models, real packaging and grocery store demonstrations. Finally, evaluation of the education programs includes some or all of the following: knowledge uptake, patient satisfaction
and change in behaviour. One program provides “game days” consisting of review of the patients’ understanding of the educational material. Immediate feedback is given to the patients and incorrect responses are then reviewed with the group.
Literature review of best practice on CR patient education:
A literature search of CR guidelines was conducted for information regarding patient education. Five guidelines were included [19
]. Data was extracted and combined into 5 categories: content (educational topics and materials), special considerations (groups which education should be adjusted), effectiveness
(principles for effective teaching and learning), mode (delivery format), and evaluation. Table 2 summarizes the results from this literature review.
Patient focus group:
Focus groups are collective discussions that are designed to explore a specific set of issues. They are a qualitative technique appropriate for exploring patients’ knowledge and experiences, examining not only what they think but why they hold a particular opinion. They can reveal dimensions of understanding that often remain untapped by quantitative data methods. Thus, focus groups explore people's understanding of issues by encouraging interaction between research participants [70
We used this approach to determine patients’ experience with the education they were receiving in the CR program prior to any changes made to the curriculum. Analysis of 9 CR patients’ narratives-composing 1 focus group-identified key themes and issues about previous patient education. Using qualitative framework approach, we coded participants’ narratives and grouped together under themes [70
]. Main themes that emerged are described in Table 3.