Proceedings of the 1st Joint ISPD/EuroPD Congress August 28 – 31, 2004, Amsterdam, The Netherlands Peritoneal Dialysis International, Vol. 25 (2005), Supplement 3
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ORIGINAL ARTICLE
PERITONEAL DIALYSIS TRAINING: A MULTISENSORY APPROACH
Alison Neville,1 Jean Jenkins,1 John D. Williams,2 and Kathrine J. Craig2
Undertaking peritoneal dialysis (PD) therapy poses a challenge to all patients with renal failure. The potentially high risk of infection makes it essential that patients undertaking PD have adequate training and ongoing support. Over recent years, increasing numbers of elderly patients, patients with significant learning disabilities, and patients with marked comorbidities have been accepted onto renal replacement therapy programs. For those undertaking PD in particular, this has posed new educational challenges. The Community Dialysis Team recognized an area of weakness in their current training program for these patient groups. The degree of literacy skills as well as the volume of written material and the amount of medical terminology used did not result in a user-friendly training program. A collaborative approach involving various members of the multidisciplinary team designed an appropriate training program for patients with learning disabilities. The new program included (1) a photographic bag-exchange procedure; (2) the provision of simple, step-by-step instructions on audiotape; (3) a new assessment sheet where words were replaced with symbols; (4) a redesigned daily record sheet (used to monitor clinical parameters); and (5) a simple contact card. The quality of the new training program was assessed by a small pilot study evaluation. The reduction of training times and the satisfactory peritonitis rates suggest that the new multisensory training program could be successfully implemented. The use of pictorial aids and more symbols, with less focus on the written word, made PD training a viCorrespondence to: A. Neville, PD Unit, Directorate of Nephrology and Transplantation, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW Wales, United Kingdom.
[email protected] Received 26 August 2004; accepted 20 December 2004.
able option for many individuals, including elderly patients and those with learning disabilities. The increased use of pictorial aids and symbols may also be helpful in training patients where there is a language barrier as well as the pediatric population. Perit Dial Int 2005; 25(S3):S149–S151
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KEY WORDS: Training program; learning disabilities; multisensory.
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major component of the peritoneal dialysis (PD) nurse’s role is to train and support patients to carry out dialysis in their own home. Over recent years, the PD cohort has expanded to include a growing number of patients with various forms of learning disability. It was recognized that these patients had specific learning needs that were not being adequately addressed by current training programs. This cohort also included a more elderly client group who may present with uremia and numerous comorbid conditions. For differing reasons, each of these patient groups has difficulty in learning and retaining information. In order to minimize complications in therapy, an effective educational program that was adaptable and able to meet individual training goals was considered essential. “In patients with chronic renal failure, for which cure is not a realistic goal, maximizing functioning and well being should be primary objectives of care” (1). A review of the literature on the health needs of individuals with learning disabilities identified that many authors had noted the low priority given to this group (2,3). In addition, the UK Disability Discrimination Act, S149
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PD Unit,1 Directorate of Nephrology and Transplantation, University Hospital of Wales; Institute of Nephrology,2 School of Medicine, Cardiff University, Heath Park, Cardiff, Wales, United Kingdom
PROCEEDINGS OF THE 1ST JOINT ISPD/EUROPD CONGRESS NEVILLE et al.
1995 made it illegal for any provider of a service in the UK to “discriminate against a disabled person by refusing to provide or offering a lower standard of service” (4). The Act also suggested that providers have a duty of service to make adjustments and make reasonable steps to change practices, policies, or procedures to facilitate the use of the service. The existing training program required a degree of literacy, spelling, and memory skills that were often diminished in patients with learning disabilities and in those with uremia. Informal feedback from patients indicated that they felt that the training program was neither patient centered nor appropriate, and that a simpler approach would be better.
FEBRUARY 2005 – VOL. 25, SUPPL 3 PDI PD TRAINING: A MULTISENSORY APPROACH
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METHODS
1. Large amounts of reading material: required literacy, comprehension skills, and concentration; 2. Medical terminology: difficult to comprehend; 3. Lengthy written procedures: required a high degree of processing skills; 4. Detailed information on daily assessment sheet: proved difficult to follow; 5. Evaluation: required literacy, comprehension, and spelling skills. Having identified the deficits in the current training program, the PD team then enlisted the help and expertise of other health professionals. The Speech and Language Therapy department at a local hospital became partners in the project and worked with the PD team in the initial planning stage, as did a member of the learning disability team and the media resource department. After a series of meetings, the areas of the program requiring revision were identified and an action plan was drawn up: 1. Develop a photographic stepwise guide to the bagexchange procedure (Figure 1) and provide simple, step-by-step instructions on audiotape; 2. Redesign the assessment sheet and replace wording with symbols commonly used within the learning difficulty community; S150
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Figure 1 — Examples from the photographic stepwise guide to the bag-exchange procedure.
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For the purpose of this study, patients with permanent learning disabilities and those with transient learning difficulties due to uremia were classified as having “learning difficulties.” As a preliminary step, the limitations of the current service were identified by the authors:
PDI FEBRUARY 2005 – VOL. 25, SUPPL 3 NEVILLE et al.
3. Redesign the daily record sheet (used to monitor clinical parameters); 4. Design a simple contact card.
filled the requirements of the service. The incidence of peritonitis in group 1 (traditional program) was 1 in 12 patient-months, while in group 2 (new program) the incidence was 0 episodes in 26.5 patient-months. The incidence of peritonitis in group 2 compared favorably with the Renal Association Guidelines (2002) for peritonitis incidence of 1 every 18 patient-months. CONCLUSION Feedback from PD patients with learning difficulties or uremic symptoms suggested problems with the traditional training program. Consequently, it was felt that the program required radical review. A multidisciplinary team including PD nurses, a speech and language therapist, and a media resources specialist developed a new approach to PD teaching using a multisensory approach. The project addressed the specific need of PD patients with learning difficulties or disease-related symptoms. Benefits to the patients included reduced anxiety and an increased sense of achievement and ownership of the training process. This project enabled patients to become partners in the management of their disease with the adaptation of the program to the patient, not the patient to the program. In addition, an unexpected finding was improvement in staff morale due to a partnership approach with other teams and a sense of achievement in making a real difference in training patients with learning difficulties. REFERENCES 1. Clang B, Clyne N. Well-being and functional ability in uraemic patients before and after having started dialysis treatment. Scand J Caring Sci 1997; 11:159–66. 2. Graham K. Better health care and learning disability. Nurs Times 2001; 97(8):39–40. 3. Bollands R, Jones A. Improving care for people with learning disabilities. Nurs Times 2002; 98(35):38–9. 4. The Disability Discrimination Act. London: Department of Health; 1995: section 2.7. 5. Smythe I. The Dyslexia Handbook 2000. Part 2. London: British Dyslexia Society; 2000: 72–3.
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Following production of the new training program and prior to its introduction into clinical practice, care was taken to ensure that it was “fit for purpose” and delivered an effective training package within a realistic time frame. To ensure that the new program was at least comparable to the original version, a small pilot project was carried out. Prior to training, the next 10 patients awaiting training had their levels of learning difficulties assessed using a validated assessment tool obtained from the British Dyslexia Association (5). These 10 patients were then randomly allocated to be trained using either the traditional or the multisensory training tool. Quantitative and qualitative analyses were carried out on the training process to ensure that the programs were comparable. The age of the two patient groups was significantly different, with group 1 (traditional program) having a median (interquartile range) age of 67 (61 – 75) years; group 2 (new program) patients were older: 73 (72 – 80) years; p = 0.01 (Mann–Whitney test). Of the 5 patients in group 1, 2 were identified as having learning difficulties; 3 of 5 in group 2 had learning difficulties. The mean ± SD numbers of days of training required for each group were 3.7 ± 0.97 and 3.2 ± 0.27. The nurses undertaking training kept a qualitative and quantitative record of the training process. Qualitative analysis of the processes involved in training patients used the technique of theme identification. Quantitative analysis was undertaken of the length of time (in hours) spent on each type of intervention. The interventions were found to comprise 5 main themes: (1) practical demonstration, (2) reassurance and discussion, (3) evaluation, (4) revision, and (5) supervision. There was a reduction in supervision time and revision time in group 2 patients (p = 0.01, Mann–Whitney test). This indicated that the modification of the training program resulted in less supervision and revision being required. An analysis of peritonitis rates was used as an indicator of quality assurance that the training program ful-
PROCEEDINGS OF THE 1ST JOINT ISPD/EUROPD CONGRESS PD TRAINING: A MULTISENSORY APPROACH
