**4. Education of the renal transplant patient**

Studies show that the education of the transplanted patient is a concern of professionals of the different health disciplines and is considered an important element in the sense that the learning that the patient does inside the health establishments does not remain only inside these places, as it also takes place outside these contexts through the transfer of knowledge to solve day-to-day issues.

These processes of articulation/adequacy between what is taught and what is learned and applied constitute an effective mechanism of success for the different intervening parties. For the patient, it represents knowledge and mastery of new skills to deal with the challenges brought by the disease; for the health institutions it represents a reduction in the number of readmissions, complications, and treatment costs; for society, it means rapid integration of the person in family, work, relational and social life.

The above is part of the problem that health education can play in the empowerment of transplanted renal patients.

The literature recognises that renal transplantation, although the best treatment option for the chronic renal patient, can nevertheless represent a major challenge for this population [42–44].

Kidney transplantation determines a path marked by the need for immunosuppressive medication throughout life, risk of infection and complications due to immunosuppressive medication, risk of organ rejection, obesity, hypertension, diabetes, malignancy, etc. [24, 43].

In this context, the issue of autonomy becomes relevant to the extent that the patient needs to cope with many of these challenges brought about by the transplantation. The answer lies in learning skills that facilitate self-care, such as learning to recognise the signs and symptoms of rejection and the need to adhere to immunosuppressive medication [43].

Chronic disease often affects the patient's ability to perform the activities of daily life, a situation that is associated with kidney transplantation. Patients experience emotional and instrumental difficulties after transplantation, which are often a burden for them and their families [45]..

Therefore, patient education is relevant in structuring the patient's day-to-day life and in the transition process. The implementation of a teaching-learning approach to strengthening the patient's ability to cope with the transformations resulting from transplantation highlights the nurses' role in preventing complications and promoting the health of this population group. The purpose of the educational process is to promote the skills and training necessary for the patient's return to normality [43, 46].

Education programmes take on different features according to the places where they take place. For instance, in Turkey, transplant units show dysfunctionalities regarding the way teaching is provided to transplanted renal patients. Patient education does not take place in the postoperative period and sometimes only a single education session is offered to the patient at discharge. Follow-up after discharge and patient's adherence to treatment are not assessed. However, nurses are in an excellent position to recommend and counsel the patients at the different stages of the transplantation process [43].

Been-Dahmen, and colleagues evaluated the effectiveness of a nurse-led support intervention for post-transplant patients. The intervention brought together several key elements, such as a holistic approach, assessment of patients' needs and preferences, shared decision-making principles and empowerment. They held four sessions: the first session focused on self-care assessment (a web-based program was created for this purpose); the second and third sessions focused on problem-solving identified by patients, in the fourth and final session, they discussed the progress made in relation to the results achieved, skills learned and other challenges that arose. They also carried out telephone follow-ups. Results showed in the experimental group, problem-solving skills, higher levels of medication adherence and higher levels of perceived quality of life. The authors concluded that the intervention was feasible and acceptable for patients and professionals. However, the small sample size did not allow predicting the potential effects of the intervention on patients' well-being and self-care behaviours [23].

The relevance of an educational programme tailored to the patient's needs is highlighted in the study by Anderson and colleagues. The programme is based on the patient-centred approach and the principles of Academic detailing. Consisting of three educational sessions on medication, rejection and healthy lifestyles. The sessions were started in the seventh week post-transplant and were conducted by nurses from the Norwegian Transplant Unit. Prior to the implementation of the programme, all nurses involved in the programme were trained to better understand the programme. All interviewees showed unanimity regarding the added value of the programme in increasing knowledge and adaptation to the new situation. For them, the patient-centred approach is highly appreciated as it addresses what is important for each person, taking into account the person's situation before starting the sessions. The existence of a programme designed according to the patients' preferences, values and needs are of great importance, as it means developing actions more focused on their uniqueness as individuals. Guided by the goal of reconciling education with personal needs, lifestyles and family context, this type of programme is particularly appreciated by patients and has positive effects on self-care [44].

Lillehagen, and colleagues present the results of their study. They explore how the new educational programme for transplant recipients is rooted in the daily routine of

#### *The Dialogue between the Patient's Educational Needs and the Knowledge Transmitted by Nurses… DOI: http://dx.doi.org/10.5772/intechopen.103891*

the ward. The idea was to change the way patients are educated. The new programme differs from the traditional by calling for patient involvement, claiming their individuality and differentiated knowledge according to their preferences, values and needs and includes education sessions. It consisted of five individual teaching sessions delivered by a trained nurse. The topics covered were medication, rejection and healthy lifestyles. The principles of Academic Detailing underpinned the programme. Patient involvement was developed through focus groups between the research group, the healthcare professionals, and a representative from the Norwegian Transplant Patients Association. The authors concluded that the patient-centred approach, tailored education and patient involvement proved insufficient when implementing the programme. In response, patients and nurses extended this approach to the patient's world. The context in which the programme was developed presented limitations to its implementation. With all this, they concluded that the tailored patient education programme involves a more complex understanding of practice than mapping patient needs. The contrast between the virtues of the programme and its failure led the authors to argue that in implementing a programme it is important to critically analyse the effects of adaptations, their impacts, and the underlying reasons [46].

The education of transplant patients is a key nursing intervention that integrates information and training. This set of variables circulates, irrigates and fertilises the patient's knowledge, skills and abilities to deal with transplantation. The entry of the patient into the world of transplantation is a particular aspect of the universe of kidney disease, which requires change, alliances and strategies, completely changing the way patients live, work and relate to each other.

Mollazadeh, and colleagues used teach-back training (TBT) to teach kidney transplant patients to acquire self-care skills. The method was applied to kidney transplant patients attending the clinic of an Iranian hospital. The study evaluated patients with 3–12 months of transplantation. The programme consisted of five sessions. The researchers assessed patients' self-care needs using a checklist, self-monitoring, daily self-care behaviours, early detection of abnormalities, coping strategies after transplantation, and stress management. In the different sessions, patients were asked to repeat in their own words what had been taught to ensure that the information was understood. The training sessions lasted 3 months. The results showed that this teaching method (TBT) proved to be effective, with higher mean scores on self-care behaviours in the experimental group compared to the control group. Before the intervention, no statistically significant differences were found in the self-care scores of both groups. The small sample size and its implementation in a single centre do not allow generalising the results to other settings [47].

Hu, and colleagues, describe the effects of an education programme on the transition from hospital to home in a group of kidney transplant patients. The study took place at a hospital in Chengdu, China. Patients in the control group received routine care, teaching given orally on admission and during hospitalisation, and a written medical and nursing summary related to medication, diet, exercise, etc. at discharge. A telephone follow-up was performed by the nurse 1 week after discharge, and for 1 month, reminding the patient of aspects regarding outpatient follow-up and general health issues [45].

The experimental group was submitted to a care transition programme at admission and during hospitalisation. On admission, a booklet on transplant management issues was distributed and the patient received an individual teaching session based on the TBT method. Several assessments were performed, namely the risk of early admission and the patient's drug profile history as a reference point. Educational material was sent online and answers to doubts were sent via WEB-Chat.

During hospitalisation, the patient received information about the preoperative, surgery and postoperative care. He also received a new book, now dedicated to preoperative, surgery and postoperative issues. A session on post-operative care was administered, informing the patient about possible complications and adverse effects of medication. The teaching programme ended with sessions directed at self-care behaviours at home and medication management at home. Along with the individual sessions the patient received a new booklet on these issues. The online educational material and the WEB-Chat for clarification of questions were maintained. At discharge, an individualised discharge plan was developed involving the doctor, the nurse, the patient, and a family member. The post-discharge period was followed by a follow-up once a week for 1 month. The follow-up was carried out in a structured way, using a follow-up form. Patients could contact doctors and nurses via WEB-Chat whenever necessary. The teachings were performed by a registered nurse. The experimental group was better prepared for discharge than the control group and had a lower readmission rate.

Video education was another of the alternatives that some authors found to educate the patient. Authors used storytellers told by 25 patients who had been transplanted for at least 8 months and had success stories of medication adherence. Through filmed interviews, the selected group informed their peers about aspects considered essential for medication adherence. The interviews were semi-structured and guided by a script composed of questions about medication. The final product was the creation of a video based on the theory of planned behaviour and consisting of 11 storytellers acting as role models in the management of medication in daily life. Messages were left in the video to encourage patients to adhere to medication. However, the effects of this teaching method were not evaluated [48].

When aligning the methods of the previous study with the study of Mansell and colleagues, it can be seen that the use of the video to stimulate medication adherence, plus the adherence contract after kidney transplantation, was another of the teaching methods thought to ensure medication adherence in transplanted kidney patients. The effectiveness of the planned strategies was not evaluated [49].

The literature also contains a wide variety of studies on therapeutic adherence in the post-transplant period. Some have used behavioural techniques [50] others supportive interventions [51] and others medication administration aids. What is noted is the lack of a standardised approach to educating the patient or strategies facilitating medication adherence [52].

Given the nature of this work, we do not expect to find unique solutions that will reveal a singular method to teach the transplanted renal patient. The literature consulted revealed a panoply of studies addressing this topic and all of them seek to stimulate the patient towards self-care behaviours within the framework of empowerment.

On the other hand, the variety of themes is extensive, and many studies have a very particular focus. In our analysis, we sought to focus mainly on the studies with broader themes in order to allow for a broader reflection on this issue.

Patient education is undoubtedly considered crucial in the management of transplantation because it is a challenging condition for the patient. Many aspects are at stake, and all are interrelated. Knowing how and when to do it is crucial for a healthy transition and adaptation to the new condition and for the success of the transplant.

This set of reasons may support the thesis that not only patients need to be trained, but also health professionals, so that the teaching delivered to the patient is more structured and facilitates its continuity among peers [53].

*The Dialogue between the Patient's Educational Needs and the Knowledge Transmitted by Nurses… DOI: http://dx.doi.org/10.5772/intechopen.103891*

While it is true that the variability of programs, as well as the issues related to the sample size, the diversity of the instruments used to assess the patients' knowledge and behaviours in addition to their reliability and validity, does not allow for the generalisation of results. In fact, Urstad, and colleagues analysed nine controlled clinical trials on the effectiveness of educational interventions in the kidney transplant population. The analysis showed that, as a rule, the interventions were not properly detailed, making replication in other settings difficult. The quality of the studies is also questioned due to the lack of transparency and inadequacies in the details of the documentation of the interventions and their effects on outcomes [54].

Another factor to take into consideration is the measurement of outcomes over time because most follow-ups do not go beyond 1 months and therefore do not guarantee their effectiveness on the timeline. Longitudinal studies are recommended to assess whether changes persist over time.

The heterogeneity of the interventions makes a comparison between interventions difficult and therefore limits the determination of the strength and quality of each intervention.
