Assessment:Principles and Practices

Introduction

Heart Failure Programs are designed for people whose heart condition interferes with their quality of life. The program is designed to give some control to the client by teaching better ways to manage their illness and make sure clients know what to do in a crisis. The goal of any heart disease education program is to assist the client to achieve their best physical, social and psychological outcome following a diagnosis of heart failure, helping to slow the progression of the disease, and improve quality of life. Much has been reported on patient education, discharge planning, and education support for the heart failure patient, (Kleinpell & Gawlinski, 2005)(Kleinpell, 2004)(Schneider, Hornberger, & Booker, 1993)(Naylor, Brooten, & Jones, 1994) (Koelling, Johnson, & Cody, 2005) but most of these education plans offer minimal or no support once the client has left the hospital. In review of the education plan for heart failure clients at our hospital, it has been identified that there is minimal post hospital discharge support, this assignment will look at a current project that I am involved with, expanding upon the current plan adding assessment as a tool to facilitate a heart failure (HF) program that adds support beyond the hospital admission (appendix I). Prevalence and incidence of heart failure (HF) are increasing substantially. This is mainly due to improved treatment of myocardial infarction and hypertension, but also to the subsequent improvement in prognosis. It is reported that the development of heart failure is occurring at an earlier age, the life time risk is reported as 1 in 5 at age 40 (McMurray, Petrie, Murdoch, & Davie, 1998, p. 9) (American Heart Association [AHA], n.d.).

Summary

The 10 week curriculum is intended for clients and their families living with, or at risk for developing cardiac disorders, specifically heart failure (appendix II). The aims of the customized workshops within the cardiac outpatient clinic are to optimize client adoption of lifestyle changes that promote optimal cardiac health, compliance with medications, i.e., ACE-inhibitors, angiotensin II receptor blockers (ARB), beta-blockers, and diuretics, and to inform clients on how to recognize signs of worsening heart failure and how to manage it (National Heart Failure Training Program [N-HeFT], n.d.) (Stromberg, Martensson, Fridlund, & Dahlstrom, 2001). Client information regarding heart failure, management and self-care has historically been given in the hospital and after discharge at the outpatient clinic, or in the primary care setting (Grady, Dracup, & Kennedy, 2000) (Remme & Swedberg, 2001). Our hospital identified that planning before discharge has been ineffective and many patients have a poor social network, which influences their total life situation. The information needed to optimize self-care and to increase the ability to manage associated signs and symptoms is well documented (American College of Cardiology [ACC], n.d)(European Society of Cardiology [ESC], n.d.)(AHA). The Working Group on Heart Failure of the European Society of Cardiology (ESC), The American Heart Association (AHA), The American College of Cardiology (ACC) and The Australian Heart Foundation have established aims for heart failure management programs (European Society of Cardiology [ESC], n.d.) (AHA) (American College of Cardiology [ACC], n.d.) (National Heart Foundation, n.d.). Participants will learn from experts in the area of heart failure management and will have the opportunity to network with other allied health specialists i.e. dieticians, pharmacists, stress management counselors, fitness trainers, and nurses, along with the ability to network with other program participants. The assessment procedure for this heart failure support program will involve instructor support and self assessment. The instructor assisted assessment will not result in a pass/fail or individual mark, but will be based on observation of progress, each participant's contribution is assessed using evidence from health log entries, and direct observation of participation and adoption of lifestyle change. Areas to be assessed include the general health status of the client including the preadmission functional status and the needs for health services prior to hospital admission. Evaluation of the client's health behaviors including medication and dietary compliance are paramount to the success of the program. The perceived needs from the care giver's and the client's point of view must be reviewed. The client, caregiver, and medical team should be working together to establish a care plan based on clinical assessment. Self assessment is encouraged where participants individually evaluate their own growth and contribution; this encourages a sense of involvement and responsibility on part of the participants, enabling development of independent judgment skills. There are a number of assessments built into this program on a number of levels, firstly the client identification/referral. Initial assessment is more of a chart review and interview that identifies the patient as having some form of heart failure or heart failure risk. Once the client is identified, they are scheduled for a follow up appointment with the heart failure clinical support coordinator, during the meeting the clients needs are assessed to identify and recommend support services that may be appropriate. This assessment involves a background knowledge probe; a short, simple verbal questionnaire prepared by instructors for use to assist clients in identifying a personal need to partake in this cardiac program is administered. The goal is to identify at least one point or fact that the client knows and using that to lead into others recognizing that their knowledge may be partial, fragmentary, simplistic, or even incorrect. Other forms of assessment included within this program include: * Knowledge surveys to unify concepts that are needed to develop conceptual learning * Online quizzes offered in conjunction with cardiac specific education programs * Handouts with quizzes or challenge questions * Verbal assessment during programs All classroom programs are available through the convenience of on-line interactive instruction and learning tools. The internet also provides an opportunity for interaction with clinicians while providing the comfort of learning in their own home or office. Client requirements for the heart failure program primarily include a readiness to change along with a willingness to learn and actively participate. Other requirements include the identification of access to computer resources. Clients participating in classroom programs are given a personal heart failure notes log, and are encouraged to bring this to all appointments and classroom sessions to take notes and capture personal thoughts and questions. Clients are also encouraged to bring any articles, brochures, or information found for group discussion e.g. diet recommendations, recipes, and internet resource sites. Clients are encouraged to participate in documenting and tracking their own vital signs and medication management. Participants will learn from experts in the area of heart failure management and have the opportunity to network with other course participants. Client assessment is designed to promote and facilitate the active participation of heart failure clients in their own healthcare management; this in turn will have effects that directly impact the clients' health, and quality of life. Clients will be invited to take knowledge surveys at the beginning and end of each module. A survey consists of course learning objectives framed as questions that ask the client to rate their self knowledge or mastery of particular objectives. All assessment will be formative with objective question types including true/false, multiple choice, multiple response and matching questions. All assessment will be offered in an open book nature, available both on-line and in written form for the classroom. Optional supplemental on-line learning courses will be available for client self directed and self paced learning. Due to the objective of the program- increasing knowledge, improving medication compliance and adoption of life-style changes in management of heart failure clients, instructors need to be aware that any assessment given is aimed at being meaningful to the clients' personal interest in their own health. Instructors are encouraged to provide an environment where the clients are treated as peers accepted and respected as intelligent experienced adults whose opinions are listened to, honored and appreciated. Intellectual challenge should be balanced to ensure participants are not challenged beyond their present level of ability but at the same time do not become bored. It is recommended that instructors remember that optimal adult learning programs, where adults learn best, both students and educators also have fun (Knowles, 1986). Assessment accommodations may include, * Flexible scheduling: Brief testing sessions with additional time if requested * Flexible setting: Individual or in groups with discussion * Flexible assistance: Assist participants with any questions as they come up, if appropriate and with participants approval share finding with group taking into consideration, travel time, work commitments, family responsibilities, and disabilities.

Conclusion

In spite of evidence-based guidelines and multiple randomized clinical trials to guide care, heart failure (HF) hospitalization rates are high, often due to poor after discharge follow-up. Hospital data shows that approximately 20% of heart failure patients are readmitted within 1 month of discharge, and 50% within 6 months (Galbreath, Krasuski, & Smith, 2004)(Aghababian, 2002)(Kleinpell & Gawlinski, 2005)(Butler, Arbogast, & Daugherty, 2004). As many as 50% of these admissions may be avoided with discharge planning and after discharge follow up (Grady et al., 2000)(Hardin & Hussey, 2003)(Barth, 2001). Inadequate client education and non adherence to medications may account for as many as 40% of readmissions. Multiple risk factors have been associated with an increased risk of readmission or death. The elderly are at high risk as they are often ill-prepared to make the life-style changes that can improve outcomes (Roe-Prior, 2004, p. 534). All age, not just the elderly, are at risk of readmission if inadequately prepared due to insufficient education and support. Other contributing factors have to do with the clients self care measure and the ability to make the necessary lifestyle adjustments. Many clients fail to adhere to the medical plan due to lack of confidence or understanding of how implement change (Conway, p. 123). For instance, few clients have the knowledge of how to follow a low-sodium diet (Koelling, Johnson, & Cody, 2005, p. 179). Noncompliance with medications and diet can lead to worsening symptoms and readmissions (Jaarsma, 2005, p. 833)(Krumholz, Amatruda, & Smith, 2002, p. 83). Non-adherence may result from conditions beyond the client's control, reinforcing the need to include family and a clinical support group to meet the educational needs of these individuals. Educational needs are unique for the individual, and the process of assessment can be threatening to the adult learner. The client needs to have a readiness to change. Potential triggers to change health care behavior include the client's realization of the importance of the change as well as energy level, physical condition and current stressors (Dalton & Gottlieb, 2003). One approach to successful education is a client centered approach that focuses on the clients perceived needs (Anthony & Hudson-Barr, 2004). Anthony and Hudson-Barr reported that the client's perceived educational needs do not necessarily match the needs identified by the health care team (Anthony & Hudson-Barr). The client's perceived needs must be viewed as a priority to foster and encourage the adoption of life style adjustments. Clients are interested in learning about how to monitor their symptoms and progress, as well as how to seek assistance. Clients require information about daily weights, and how their symptoms relate to their self care behaviors (Conway, 2006). Being cognizant of the client's self-identified needs will promote success of both the client's competency and self confidence along with the programs objectives. This can be reinforced with quality assessment. Assessment needs to support the development and progress of the client. Criterion referenced assessment can describe development and progress in terms of skills developed, attitudes exhibited and knowledge acquired. Various standards or criteria for each of these characteristics can be identified and organized in order of increasing sophistication; performance can then be compared to the standards. This can be seen in the assessment rubric in appendix III. With any client education, resources and teaching techniques are designed to encourage and/or reinforce client behaviors with the goal of improving quality outcomes. Assessment is an integral component of this, if assessment fails then the program has failed. In this instance this may have a devastating impact on the client's life. Assessment is the most significant prompt for learning (Boud, 1995). One of the most important outcomes of research on student learning is the recognition that learning must fundamentally be seen as relational (Ramsden, 1987). When effective reinforcement processes are employed, the likelihood of positive learning outcomes and student satisfaction can be significantly increased. This can be achieved through authentic assessments "contextualized intellectual challenges not fragmented and static bits or tasks" (Wiggins, 1989, p. 711) The design of assessment is central to capturing the benefits of group work and avoiding its pitfalls. Assessment defines the character and quality of group work. In fact, the way in which participants approach group work is largely determined by the way in which they are to be assessed. Careful coordination of assessment can help evaluate the criteria for process, as appropriate to the subject and group work objectives for example: regular meeting attendance equity of contribution evidence of cooperative behavior appropriate time and task management application of creative problem solving use of a range of working methods appropriate level of engagement with task development of self management competencies evidence of capacity to listen responsiveness to feedback. A clear understanding of the intended learning outcomes of the subject in which the group or individual work occurs is a useful starting point for determining criteria for assessment of the group or the individual . Once these broader learning requirements are understood, a consideration of how the group task, and criteria for assessment of that task, fit into those broad requirements can then follow. It is challenging to apply traditional forms of assessment to the framework of this clinically driven heart failure program, not because it cannot be implemented but because the participants are attending voluntarily, looking for a holistic informal education that is non-threatening but at the same time aiding in the development of problem solving and application of skills that will promote a sense of health and well being. Assessment is a way to keep the individual returning to the group; challenging and at the same time intriguing, social in nature but nurturing, motivational toward self awareness driving adoption of change. Educator Malcom Knowles used Piaget's and Erikson's work to study the adult learner, in examining personal and cognitive development he identified adult learners as needing independence and the ability to exercise control. (Knowles, 1986) Adults returning to education come from a wide variety of backgrounds and will attend classes for any number of personal reasons. It is important that quality informal assessment be able to encompass all from the business executive to the homemaker, the minimally educated to those with excellent prior educational backgrounds, this is key in keeping the clients in class. Content and curriculum are important but assessment holds the key to the success within the heart failure program as the stakes are high for the individuals and families in need of the service. This heart failure program is in a development phase and has much work that needs to be incorporated beyond the scope of this paper. Clinically there are many reasons to justify support of this group, in assessing the educational justification, time will tell. If we can successfully support the needs of this adult learner group, keep attendance, promote medication compliance and encourage life style changes, then we can impact quality of life and claim a success. The stakes are high when it comes to disease management education.

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