Nurses as educators in the comprehensive heart failure care programme—Are we ready for it?

Abstract Aim To assess education frequency and nurses' comfort when educating patients hospitalized in different hospital units to prepare them for self‐care. Design A cross‐sectional survey. The study included nurses working in units where HF patients were hospitalized. Results The average score for comfort of education was 5.43 (between “slightly comfortable” and “very comfortable”). The most comfortable topics were “Daily weight monitoring” (5.81 ± 1.25), “Signs/symptoms of worsening condition” (5.77 ± 1.19) and “Fluid restriction” (5.76 ± 1.23). The respondents felt least comfortable when teaching about “Medications” (5.06 ± 1.35) and “Low‐sodium diet” (5.31 ± 1.42). The mean score obtained for education frequency was 5.21 (SD 2.51). The nurses most frequently educated their patients on such topics as “Daily weight monitoring” (5.82), “Signs/symptoms of worsening condition” (5.9) and “Fluid restriction” (5.92). Conclusions Polish nurses are not ready to perform comprehensive HF care tasks without preparation.

idea about the condition, HF patients may inadequately or unconfidently use their self-care skills. Numerous authors have shown that self-care intervention produces significantly better treatment outcomes in HF patients than the lack of such behaviours (Barnason, Zimmerman, & Young, 2012;Seto et al., 2011;Shao & Yeh, 2010).
The improvement of self-management skills, resulting from disease management programmes, has yielded beneficial effects in adult HF patients, especially with respect to their well-being, functioning, symptoms, morbidity and prognosis. According to practice guidelines, patient education concerning a heart-healthy lifestyle remains a crucial element of effective disease management in adults with HF (HFSA et al., 2010;McMurray et al., 2012;NHFA CSANZ et al., 2018). It is very important that patients who are actively engaged in self-care understand their disease and treatment regime (Mahramus et al., 2013). Studies have shown that patient education efficiently and cost-effectively prevents rehospitalizations and that patients' knowledge about self-care (e.g. symptom monitoring, medication compliance, diet observance) yields positive outcomes (Pressler, 2011;Simmonds et al., 2015). Nurses play a crucial role in providing patients and their families with education and preparing the former for postdischarge management of their disease.
There are several evidence-based educational topics and nursing-care performance measures which should be taken into account when managing HF: managing and recognizing symptoms, monitoring weight, diet, level of activity, medication and follow-up appointments. To adequately educate patients about self-care, nurses should have a comprehensive knowledge of HF and self-care behaviours such as managing and maintaining the control of the disease and symptoms (Albert et al., 2002).
According to Orem's theory, engagement and self-care skills may significantly reduce the need for hospitalization in cardiac patients (Cottin et al., 2004). The degree of patients' preparation depends on their ability to participate in their care. In the supportive-educational model, patients are able to engage in self-care but require education about the various aspects of therapeutic self-care behaviours (Orem, 2001). Nurses are in a perfect position not only to recognize the existing and potential health problems but also to offer supportive-educational interventions if necessary.
Some of the available study results show that nurses are not adequately prepared for education and knowledge of self-care principles is insufficient to teach patients (Albert et al., 2002;Simmonds et al., 2015). These deficits assessing the level of nurses' preparation to educate HF patients and usually include signs and symptoms of hypoperfusion hydration status and blood pressure assessment, symptom management and diet and medication restrictions. It is believed that too little time is devoted for patient education in hospitals (Albert et al., 2002). Patients do not know enough about heart failure and treatment recommendations.
The ordinance published by the Polish Minister of Health has defined the main goal and specific objectives of the comprehensive heart failure care (Polish, Kompleksowa Opieka nad Osobami z Niewydolnością Serca-KONS). The main goal is to "limit the occurrence of consequences of HF," while the specific objectives are as follows: early discovery of HF and determination of its aetiology, inhibiting disease progression, optimizing the use of healthcare resources in HF care, improving lives and longevity of patients with HF and limiting the exacerbation of the disease (Balsam et al., 2018;Nessler, Kozierkiewicz, et al., 2018;Nessler, Straburzyńska-Migaj, et al., 2018;Nessler, Windak, & Oleszczyk, 2015). The proposed model of care will offer multidisciplinary, continuous and coordinated care, aiming to engage the patient in his or her treatment. It aims to deliver a comprehensive scope of care by combining outpatient care, pharmacology, interventional treatment (invasive cardiology, electrotherapy, cardiac surgery) and rehabilitation.
These teams will provide the necessary services: medical care, nursing care, education, drug administration and monitoring of patient compliance with physicians' advice. Consultant cardiologists will offer ongoing support to general practitioners in diagnosing and treating patients with HF. Education of patients about self-care carried out by nurses should translate to a lower number of acute decompensated HF episodes and, consequently, slower the progression of the disease.
In the light of the previously demonstrated idea of slow delivery coordinated care for patients with heart failure and knowledge deficits in Polish nurses, which might lead to difficulties in delivering adequate patients education, we decided to assess the frequency of patient education provided by nurses before discharge and the level of comfort they experience when fulfilling the tasks of educators, preparing patients for self-care.
The aim of the study was to assess education frequency and nurses' comfort when educating patients hospitalized in different hospital units to prepare them for self-care. The following questions were posed: (a) Do nurses perform tasks related to the delivery of pre-discharge patient education among all patients and/or their families? (b) Do nurses feel comfortable in the role of educators before discharge planning? (c) What determinants affect the frequency of education and nurses' level of comfort when delivering patient education? Part II contains general questions about educating patients (the use of teaching resources such as videos and handbooks, time spent educating patients, contact with patients' family members, feelings related to comfort and confidence while delivering education). Answers are provided on a 5-point Likert scale (ranging from "never" to "always").

| Study design and sample
Part III is composed of questions about the most common topics discussed during heart failure education (illness beliefs, medications, low-sodium diet, physical activity, weight monitoring, fluid restriction, symptoms of fluid overload). In this part, respondents determine the following: 1. the level of their comfort while discussing HF topics using a 7-point Likert-type scale, where 1 denotes "completely uncomfortable" and 7 "completely comfortable," 2. the frequency of education about a given theme using a numerical scale from 0 ("I never discuss this topic")-10 ("I always discuss this topic").
We obtained the author's permission to use the questionnaire.

| Statistical analysis
Comparisons of quantitative variables in two groups were conducted with Mann-Whitney test. Comparisons of quantitative variables in more than two groups were conducted with Kruskal-Wallis test. Dunn's test was used as post hoc procedure. Correlations between quantitative variables were assessed with Spearman's correlation coefficient. Analyses were conducted at the 0.05 level of significance.

| RE SULTS
Most of the group studied were women (90.79%); the mean age of the respondents was 42.55 ± 10.03 years. A large proportion of the nurses had higher education (74%) but did not undergo postgraduate training (only 25% of the nurses had a specialty). More than half of the respondents were employed at a university hospital (52.96%), in a telemetry unit (34.21%) and in an intensive cardiac care unit (25.33%). The nurses usually worked 12-hr shifts (day-night). Work experience in the study group was 19.41 ± 11.34 years (Table 1).

| Nurses' comfort: Survey of RNs about Heart
Failure Practices Related to Delivery of Patient Education before Discharge The level of comfort was assessed using a 7-point Likert-type scale, where 1 denoted "completely uncomfortable" and 7 "completely comfortable," based on the mean score for all the questions. The mean score obtained by the respondents was 5.43 (SD = 1.13). This means that the nurses felt between "slightly comfortable" and "very comfortable" in the role of educators ( Table 2). As for the level of comfort in educating patients about individual topics, the respondents felt most comfortable with regard to "Daily weight monitoring" (5.81 ± 1.25), "Signs/ symptoms of worsening condition" (5.77 ± 1.19) and "Fluid restriction" (5.76 ± 1.23) ( Table 3). The mean score of nearly 6 suggests a high level of comfort when teaching about these topics. The respondents felt least comfortable when teaching about "Medications" (5.06 ± 1.35) and "Low-sodium diet" (5.31 ± 1.42). In this case, the mean score was slightly over 5, which "merely" denotes "slightly comfortable." The themes (questions) below have been listed in descending order based on the mean score obtained: from the highest mean (the highest level of comfort) to the lowest mean (the lowest level of comfort). The respondents felt the highest level of comfort (the score of c. 6 on the Likert-type scale) when educating about the importance of monitoring oneself and the need for accurate daily weight monitoring and measuring and monitoring fluid intake. The nurses experienced the lowest level of comfort (score below 5) when teaching about sexual activity and taking particular groups of medications.
What is worth noting is that the respondents did not obtain the highest possible level of comfort in any of the questions (Table 4).

| Education frequency: Survey of RNs about Heart Failure Practices Related to Delivery of Patient Education before Discharge
Education frequency was assessed using a numerical scale ranging from 0 ("I never discuss this topic")-10 ("I always discuss this topic") (every point denotes further 10% in education frequency).
The mean score obtained by the respondents was 5.21 (SD 2.51), which means that about 52% of patients under their care were educated about all the topics listed in the questionnaire ( Table 2).
The nurses most frequently educated their patients on such topics as "Daily weight monitoring" (5.82), "Signs/symptoms of worsening condition" (5.9) and "Fluid restriction" (5.92). The mean scores of nearly 6 indicate that education about these topics was provided to approximately 60% of patients under the respondents' care ( Table 5).
The least frequent education topics were "Medications" (4.49) and "Low-sodium diet" (4.87). In this case, the mean scores were below 5, which means that fewer than 50% of the respondents' patients received education on these topics (Table 6). Just as with the comfort level assessment, the nurses gave the lowest scores to the topic concerning the aim and adverse effects of taking HF medications. In this case, the respondents' score was below 5, which means that the topic was taught less than half of the time. The topics most frequently taught by the respondents included fluid restriction, weight monitoring and signs/symptoms of worsening condition, and the need for regular office visits. The results of the analysis demonstrated that over 60% of patients received education on these topics. Table 6 presents the themes (questions) listed in descending order based on the mean score obtained: from the highest mean (the highest education frequency) to the lowest mean (the lowest education frequency).

| The relationship between selected determinants and comfort and frequency of education
The analysis of correlations between selected variables and the comfort in and frequency of delivering HF patient education demonstrated a significant positive relationship between the age of the respondents and nurse comfort (r = .166) and education frequency (r = .123). In other words, the older the nurses, the greater the comfort in and frequency of delivering education. A similar positive correlation was observed between work experience and nurse comfort; that is, the longer the experience, the higher the comfort in delivering education (r = .134). The analysis of the relationship between gender and the comfort in and frequency of delivering education revealed a statistically significant difference between male and female nurses. p-values lower than .05 indicate that the comfort in and frequency of delivering education were significantly higher in the group of female nurses ( Table 7).
The post hoc analysis of correlations between the type of hospital and nurses' comfort in and frequency of delivering education showed that employees at provincial hospitals experienced significantly higher comfort than those employed at city and university hospitals; also, the former group delivered education with significantly higher frequency (Table 7).
As for correlations with the respondents' workplace, the highest comfort in delivering education was observed in employees of the cardiac rehabilitation unit (5.75 ± 0.82) and cardiac intensive care unit (5.71 ± 1.15). Similar results were obtained with regard to education frequency, which was the highest in the cardiac rehabilitation unit (70% of patients), followed by the cardiac intensive care unit (56% of patients) and the telemetry unit (52% of patients). The lowest comfort was experienced by nurses in the emergency care/ short-stay unit (4.78 ± 1.63), who also demonstrated the lowest frequency of delivering education (43% of patients). The analysis of the relationship between the respondents' university education and the comfort in and frequency of education delivery showed that this was not a variable that had a significant impact on the parameters studied. The opposite applies to postgraduate training as nurses with a specialty demonstrated a significantly higher level of comfort and education frequency than those without a specialty (5.84 ± 0.78 versus 5.3 ± 1.2; p = .001 for comfort;

TA B L E 1 Characteristics of the study group
5.8 ± 2.42 versus 5.01 ± 2.51; p = .015 for frequency). As for the type of specialty, the analysis showed that the respondents with a specialty in cardiac care presented a significantly higher level of comfort and delivered pre-discharge education to HF patients more frequently than those with any other specialty (6.29 ± 0.62 versus 5.36 ± 1.14 for comfort; 7.08 ± 12.28 versus 5.06 ± 2.47 for frequency).

| D ISCUSS I ON
Heart failure is a complicated clinical entity leading to patient's premature death. The appropriate management of heart failure includes pharmacotherapy, non-pharmacologic treatment and early recognition of decompensation. Every deviation of optimal treatment methods contribute to the steady or rapid worsening of the patient's status, which in turn activates the neurohumoral systems wasting the failing heart's resources and shortening life expectancy.
The knowledge about optimal heart failure management is crucial for the patient to live longer, and any kind of measures or anyone who may contribute to better disease and symptom understanding will influence the prolongation of patients' life.
According to the guidelines, patient education is of immense importance. Also, patients should receive relevant training materials as part of their pre-discharge education (Paul, 2008 and pursue teaching strategies that will allow patients to cope with their problems (Stamp, Machado, & Allen, 2014).
According to the authors of the curriculum for heart failure, it is the geographical location and professional regulations in a given state that determine the role and duties of a nurse (Riley et al., 2016

TA B L E 4 (Continued)
blood pressure and fluids, management of symptoms and restrictions related to diet and medications (Simmonds et al., 2015).
It is worth noting that the patients included in Mahramus' study displayed a very low level of detailed knowledge on the effects of HF medications and the importance of fluid restriction. It is necessary point out that our study demonstrated that nurses rarely taught patients about these topics and felt uncomfortable while doing it.
What follows is that the problem of knowledge deficits will continue to exacerbate and translate into an unsatisfactory level of self-care our educated patients.
Despite the common knowledge that education significantly improves treatment outcomes, educational interventions are not consistently incorporated into practice. The second important result of our research showed that the overall score for the frequency of patient education was about 52% and the least frequently discussed topics were low-sodium diet and medications. This is in line with the results in other studies (Basuray et al., 2015). Stamp and colleagues demonstrated that nearly 45% of patients never or very rarely received 60 min of instructions, which stands in contrast to the guidelines which recommend this amount of time for pre-discharge self-care education (Stamp et al., 2014). Our study did not assess the time spent on education delivery but focused on the frequency of education.
Our results showed that nurses who worked in the cardiac intensive care unit experienced higher level of comfort and pre- Some researchers believe that it is better to provide education to patients in a stable condition, who have adapted to living with HF (Paul, 2008).
Another factor affecting the comfort in and frequency of education delivery was the type of hospital. Nurses in provincial hospitals felt the highest level of comfort and provided education with the highest frequency, whereas employees at university hospitals obtained the lowest scores in this respect. This comes as a surprise because one might think that nurses working in university facilities perform educational tasks regularly and that teaching should not present any serious difficulty to them. One possible cause of such a low level of nurse comfort and education frequency is that university hospitals often employ graduates in nursing and, according to the results of our correlation analysis, age and work experience had the highest impact on comfort and frequency, whereas university education did not affect these parameters. Unfortunately, we did not obtain information on the and their families as partners rather than students in the educational process (Paul, 2008). Educational interventions should take the form of two-way sessions, with patients taking an active part in the identification of their needs.
There are researchers who believe that lack of time is the most commonly reported reason for insufficient education (Baas et al., 2014;Peter et al., 2015). Other health system-related barriers include lack of support from decision-makers, difficulties with handling electronic documentation and lack of educational materials. It is possible that all these data are the basis for assessing the effectiveness of education, but they were not the subject of this work.
Our study demonstrated that nurses' postgraduate training significantly affected the comfort in and frequency of delivering education. Nurses with a specialty degree felt a higher level of comfort and delivered education more frequently than those without a specialty.
Additionally, the values of these parameters were higher in nurses with a specialty in cardiac care than in nurses with other specialties.

| Clinical and practical perspectives
These authors emphasize the need for developing systems supporting nurses, including the following: programmes with an appropriate curriculum which would improve nurses' HF self-care knowledge, motivation for nurses to pursue HF specialty, sufficient number of staff and time that would allow for pre-discharge education, streamlined educational plan documentation and outcome evaluation and incorporation of comprehensive patient education into overall HF care.

| Study limitations
Our research has a few limitations. It is essential that there is no control over how the questionnaire is filled in. Nurses could consult with each other and use other sources of knowledge to conduct the survey. In the organization of coordinated care for patients with heart failure, primary care is given an important role in the care process and only clinical nurses have participated in our study, which may not reflect the reality of the situation. Another limitation of the study is the lack of verification of work experience and courses by survey fillers and uneven group selection in terms of academic education (75% of nurses had higher education). Another limitation of the survey is the lack of information about the reasons for refusing to participate in the survey and information about which nurses did not fill in the questionnaires (personal and professional profile).

| CON CLUS ION
1. Polish nurses are not ready to perform comprehensive heart failure care tasks under CONS, without proper, careful preparation.
2. Male and female nurses' comfort in educating HF patients is higher than the frequency of education delivered.
3. The lowest level of nurse comfort and education frequency was observed with respect to the following topics: HF treatment, aim and adverse effects of taking particular groups of medications, sexual activity of patients and principles of low-sodium diet.
4. Factors affecting the comfort in and frequency of education delivery are nurses' age, work experience, gender, type of hospital and postgraduate training.

Completion of a cardiac specialty significantly affects nurses'
comfort in and frequency of delivering education about self-care to HF patients.

ACK N OWLED G EM ENTS
There was no external source of funding for this research, and no writing assistance was required.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflict of interest.

AUTH O R CO NTR I B UTI O N S
DK and BJP were responsible for the conception and design, acquisition of data, analysis and interpretation of data, drafting the initial manuscript and revising it critically for important intellectual content. DK wrote the manuscript. All authors read and approved the final manuscript.

E TH I C A L A PPROVA L
The study protocol was approved by the Independent Bioethics Committee of the Wroclaw Medical University (Approval No. KB 205/2019). All participants gave informed consent after thorough explanation of the procedures involved. The study was carried out in accordance with the tenets of the Declaration of Helsinki.

CO N S E NT FO R PU B LI C ATI O N
All co-authors have agreed to the submission and publication of this manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
All data and materials used in this research are freely available.