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Practice patterns of heart failure nurses
AAHFN Special Report
Practice patterns of heart failure nurses Marilyn A. Prasun, PhD, CCNS, FAHAa,*, Jesse Casida, PhD, RN, CCRN-CSCb, Jill Howie-Esquivel, PhD, RN, NPc, Bunny Pozehl, PhD, APRN-NPd, Beth Fahlberg, PhD, RNe, Cindy Johnson, MS, RN, CNSf, Juliet Mock, RN, MS, ACNS-BCg, Jill Quinn, PhD, RN, CS-ANPh, Karen Yehle, PhD, RNi, Linda Baas, PhD, RN, CHFN, ACNPj a
School of Nursing, Millikin University, Decatur, Illinois b Wayne State University, Detroit, Michigan c Acute Care Nurse Practitioner Program, Department of Physiological Nursing, University of California, San Francisco d University of Nebraska Medical Center, College of Nursing, Lincoln e School of Nursing, University of Wisconson-Madison f Red Deer Regional Heart Function Clinic, Red Deer, AL, Canada g ICU and Telemetry, Aurora Health Care, West Allis Medical Center, West Allis, Wisconsin h University of Rochester School of Nursing, Rochester, New York i School of Nursing, Purdue University, West Lafayette, Indiana j University of Cincinnati College of Nursing and Director of Research, The Christ Hospital, Cincinnati, Ohio
article info
abstract
Article history: Online 16 March 2012
Objective: Little is known about the practice patterns of nurses who work in the specialty of heart failure (HF). This specialty includes inpatient and outpatient sites for practice that incorporate intensive care to rehabilitation. The purpose of this study was to describe the current practice of nurses who are members of the American Association of Heart Failure Nurses (AAHFN).
Keywords: Heart failure nursing Heart failure patient education Practice patterns
Methods: A convenience sample of nurses attending the 2010 Annual Meeting of AAHFN was surveyed to determine current practice patterns. Results: The mean age of the nurses completing the survey was 48 years (standard deviation [SD] þ10), and the majority were white (85%) and female (98%). Approximately half (48%) completed a Master’s degree. The mean time worked as a nurse was 23 years (SD þ10), with a mean of 11 years (SD þ8.2) caring for patients with HF. Both HF education and physical assessment were reported to be provided frequently. Conclusion: This survey provides insight into the practice patterns of HF nurses. Continued monitoring of this role is warranted and can serve to assist the AAHFN in advancing HF knowledge and skills. Cite this article: Prasun, M. A., Casida, J., Howie-Esquivel, J., Pozehl, B., Fahlberg, B., Johnson, C., Mock, J., Quinn, J., Yehle, K., & Baas, L. (2012, MAY/JUNE). Practice patterns of heart failure nurses. Heart & Lung, 41(3), 218-225. doi:10.1016/j.hrtlng.2012.02.001.
* Corresponding author: Marilyn A. Prasun, PhD, CCNS, FAHA, Associate Professor, School of Nursing, Millikin University, Decatur, IL 62522. E-mail address: [email protected] (M. A. Prasun). 0147-9563/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.hrtlng.2012.02.001
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Heart failure (HF) is a chronic progressive disease and the most common hospital discharge diagnosis for patients aged more than 65 years.1 The number of people diagnosed with HF is increasing as our population continues to age and as medical advancements result in improved survival from cardiac problems. The Heart Failure Society of America’s 2010 Comprehensive Heart Failure Practice Guideline provides a strong evidence base for the importance of chronic HF management in promoting positive patient outcomes.2 Adherence to these guidelines of care, especially in relation to pharmacologic management of HF, has become an important indicator for quality of care. In addition to pharmacologic management, the 2010 Heart Failure Society of America Guideline emphasizes the need for comprehensive education and counseling to help patients, their families, and their caregivers in learning how to manage this complex chronic disease. Nurses play a key role in providing this needed education and counseling; however, little is known about actual practice patterns of nurses providing care to patients with HF. Albert3 notes that there is no uniformity in nursing care and no core nursing measures to guide the practice of nurses delivering care to patients with HF. There are varying roles and responsibilities of nurses providing care to patients with HF, yet there is little evidence to guide the necessary educational training required to adequately prepare nurses for the emerging role of the HF specialist nurse.4 The mission of the American Association of Heart Failure Nurses (AAHFN) is to unite professionals in the support and advancement of HF practice, education, and research to promote optimal patient outcomes. Key aspects of this organization include education on HF topics, including evidence-based practices and disease management, mentorship in clinical practice across the continuum of care, and facilitation of the conduct and translation of HF nursing research. Because little is known about actual practice patterns of nurses providing HF care, the AAHFN undertook a survey of nurses providing care to patients with HF to describe current patterns of nursing practice. HF is a chronic illness necessitating a complex daily self-care regimen including the management of numerous cardiovascular medications, daily monitoring of weight and symptoms, and ongoing adherence to dietary restrictions. The majority of individuals with this diagnosis are elderly with coexisting chronic illnesses and various types of functional limitations. Many individuals with HF have cognitive deficits or poor health literacy skills. Self-care behaviors are emphasized in the HF treatment guidelines as an essential element of HF disease management;2 however, nonadherence to the recommended HF self-care regimen accounts for approximately 50% of hospital readmissions in those with HF.5-10 In 2013, changes in the Medicare Prospective Payment System will reduce the reimbursement rates for care of patients with HF readmitted within 30 days after hospital discharge.11,12
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Therefore, it is important to understand the role of nursing in the prevention of hospital readmissions and the practice patterns of nurses who provide care to patients with HF. The literature describing practice patterns of HF nurses is limited. One study by Albert et al,13 which examined nurses’ knowledge of HF education principles (ie, diet, fluids and weight, signs or symptoms of worsening condition, medications, and exercise), found a mean knowledge score of 15.2 2.0 on a 20-item knowledge survey. Three additional studies using this same knowledge survey found similar results with a mean knowledge score for nurses ranging from 14.6 to 15.97.14-16 Education level was found to differ with registered nurses having a significantly higher mean knowledge score compared with licensed practical nurses,13 whereas a similar study found no differences in knowledge by educational level of the nurse.16 Experience level of nurses was found to make a significant difference in the study by Willette et al.15 Also, experience in the care of patients with cardiac disease resulted in higher knowledge scores in 2 studies.13,15 HF nurses had the highest scores, and they exceeded the knowledge scores of critical care, medical-surgical, or telemetry unit nurses.13 In the second study, cardiac care nurses had a higher mean knowledge score than telemetry nurses.15 Given the limited research in this area, it is important to gain more understanding of the practice role of the HF nurse and the impact this may have on the care of the patient with HF. The purpose of this study was to describe the practice patterns of nurses providing care to patients with HF. With nurses playing a key role in educating and supporting patients, families, and caregivers in the self-care skills that are needed to prevent rehospitalizations, it is important to more fully understand practice patterns to develop standards for the education and practice of HF nurses.
Materials and Methods The study used a descriptive cross-sectional survey design with a convenience sampling technique. After approval by Millikin University’s institutional review board, survey packets were distributed to 417 attendees at the 2010 annual meeting of the AAHFN. The survey packets contained a cover letter that explained the study and the questionnaire. Nurses interested in participating in the study were asked to complete the questionnaire and turn it in before the conclusion of the meeting. Responses were anonymous. Inclusion criteria for the study were registered nurses who reported providing HF education or care to patients. The study questionnaire was developed by HF nursing experts who were members of the AAHFN. It consisted of several demographic questions, 26 questions about educational practices, and 12 questions
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Table 1 e Demographic characteristics (n [ 128) Variable
Frequency
Age (y SD) Gender n (%) Male Female Ethnicity n (%) African American Caucasian Asian American Indian Other Nursing education n (%) Some college Associate degree
48.5 9.659
Not collected
2 (1.6) 126 (98.4)
Not collected
10 (7.8) 109 (85.2) 4 (3.1) 2 (1.6) 1 (0.8)
Not collected
Bachelor degree Master degree Doctoral degree Years worked as a nurse (mean SD) Practice setting n (%) Ambulatory clinic/office based Ambulatory clinic/hospital based Combined hospital/ambulatory Hospital Cardiac rehabilitation Home health
39 (30.5) 62 (48.4) 4 (3.1) 23.2 10.77
Years worked in HF (y SD) Percentage of patients with HF (mean SD)
10.9 8.21 73.87 29.5
13 (10.2) 9 (7.0)
16 (12.5) 24 (18.8) 22 (17.2) 54 (42.2) 1 (0.8) 3 (2.3)
AAHFN membership
Highest degree Associate degree Bachelor of Arts Bachelor of Science Bachelor of Science in Nursing Diploma Doctor of Nursing Practice Doctor of Nursing Science Master’s degree Medical Doctor Master’s in Public Health Master’s of Science Master’s of Science in Nursing Doctor of Philosophy Grand total
Total % 54 105 15 47 19 2 1 141 3 2 12 49 22 472
30 y Count of work_in Work_in HFP-in HFP-in-out HFP-out HFP-PP HFP-third industry PP-card PP-IM university Grand total Average 7e10 y N/A Not collected
Total % 100 88 76 12 8 10 24 2 22 342
HFP, heart failure program; IM, internal medicine; N/A, not available; PP, private practice.
about assessment practices. The educational and assessment practices were rated on the basis of the frequency of implementation in clinical practice using a 5-point scale ranging from almost never to almost always. Content validity of the tool was established through peer review by advanced practice and cardiovascular research nurses. Internal consistency of the items in the questionnaire was demonstrated by a Cronbach’s alpha of 0.96. Data collected from the questionnaire were analyzed and reported using descriptive statistics. Frequency distributions were used to organize the data, which are expressed as frequencies, percents, means, and standard deviations (SDs). Bivariate correlations were also calculated using Spearman’s rho 2-tailed significance
test. All statistical analysis was conducted using the Statistical Package for the Social Sciences version 17 (SPSS Inc, Chicago, IL). A total of 128 completed surveys were returned for a response rate of 31%.
Results Characteristics of the Nurses The mean age of the nurses who completed the survey was 48.5 10 years, and approximately half (48%) had completed a Master’s degree (Table 1). The average number of years employed as a nurse was 23.2 years,
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which is lower than the mean of 30 years for the AAHFN general population. The majority of nurses surveyed were employed in a hospital setting or a combined hospital and ambulatory care setting (59%). This is similar to the AAHFN general population, with 55% of members who report working in these settings. Nurses who completed the survey worked an average of 10 8 years in the HF setting. The majority of patients cared for by these nurses (73.8%) were diagnosed with HF. Nursing licensure was divided between Registered Nurse (56%) and Advanced Practice Registered Nurse (42%), with 41% of the Advanced Practice Registered Nurses credentialed to prescribe medications (Table 2). Nurses reported an average of 13 patient visits daily. Fifty percent of nurses reported spending 15 to 29 minutes reviewing patient information. Only half of participants (50%) reported employer support for outside continuing education. Few nurses reported working closely with a nurse who had published material (27%).
Table 2 e Nursing characteristics (n [ 128) Variable Nursing license n (%) RN APRN Licensed to prescribe n (%) Yes but do not prescribe Yes No Patients with HF managed daily (mean SD) Review of patient information n (%) 30 min to >1 h <15e29 min Employer supports education n (%) Yes Work closely with a published nurse n (%) Yes
Frequency 72 (56.3) 54 (42.2) 5 (3.9) 47 (36.7) 24 (18.8) 13.24 15.01
56 (43.7) 64 (50) 65 (50.8) 34 (26.6)
APRN, advanced practice registered nurse; RN, registered nurse.
Heart Failure Patient Education Practice Patterns
years of nursing experience was the topic of limiting alcohol intake (0.28; P ¼ .001).
Table 3 demonstrates the frequency with which the nurse participants reported providing HF education to their patients in various content areas. The nurses reported providing the most frequent patient education to patients with newly diagnosed HF and patients with chronic HF on the following topics (score > 4.0 for both patient groups): symptoms, particularly dyspnea and orthopnea, low-sodium diet, weight monitoring, medication purpose and importance of adherence, and information about contacting healthcare provider. The following educational areas were less frequently addressed, with scores < 4.0: pathophysiology (chronic HF), selecting low-sodium foods (chronic HF), limiting alcohol (new and chronic HF), common side effects (chronic HF), managing medication side effects (new and chronic HF), special medication precautions (chronic HF), adjusting diuretic medication (new and chronic HF), fluid and sodium intake (new and chronic HF), assessing a persistent cough (new and chronic HF), assessing lightheadedness (new and chronic HF), and information to bring to the follow-up appointment (chronic HF). The least frequent educational practice for patients with new HF and those with chronic HF was diuretic dose adjustment (mean 3.13 and 3.29, respectively). For those with chronic HF, nurses reported 3 other less frequent educational practices: limiting alcohol intake (mean 3.57), limiting fluid and sodium intake (mean 3.63), and managing medication side effects (mean 3.66). Certain educational practices were more common in nurses with more experience. Positive significant correlations were demonstrated between the number of years of nursing experience and several educational practices with patients with newly diagnosed HF (Table 4). The strongest correlation with the number of
Assessment Practice Patterns of Patients with Heart Failure Table 5 demonstrates the reported frequency of various types of assessments or examinations completed by nurses with each of their patients with HF. Participants reported performing the following assessments frequently with both those with new HF and those with chronic HF (mean scores 4.0; range 2.9-4.46): review of diagnosis, illicit drug and alcohol use, activity level, worsening signs or symptoms, weight, heart sounds, and rhythm and lung sounds. The following assessments were less frequently reported (<4.0) in those with newly diagnosed HF and those with chronic HF: ways to increase activity, orthostatic blood pressure, height, and measurement of body mass index. The least frequent type of assessment completed in patients with chronic HF was measurement of body mass index (mean 3.32).
Discussion These study findings describe the education and assessment practices of HF nurses in a variety of settings across the healthcare continuum nationwide. Survey respondents reported spending more time educating a new patient than established (chronic) patients. However, whether the patient with HF is newly diagnosed or chronically ill, the time spent reported by the survey respondents in assessing their patients during each visit appeared to be the same. Thus, it is expected that the nurse will spend more time educating a newly diagnosed patient than an
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Table 3 e Education practice patterns for patients with heart failure (n [ 128) Content area
Almost never/infrequently n (%)
Pathophysiology New 6 (4.6) Chronic 5 (3.9) Common symptoms New 5 (3.9) Chronic 5 (3.9) Effects of sodium New 2 (1.6) Chronic 1 (0.8) Limit dietary sodium New 2 (1.6) Chronic 1 (0.8) Read food labels New 3 (2.4) Chronic 4 (3.2) Selecting low sodium New 9 (7.0) Chronic 10 (7.8) Limit alcohol New 10 (7.8) Chronic 13 (10.2) Purpose of medication New 1 (0.8) Chronic 1 (0.8) Common side effects New 6 (4.7) Chronic 6 (4.7) When to call healthcare New 8 (6.2) Chronic 8 (6.2) Manage medication side effects New 13 (10.2) Chronic 17 (13.3) Consequence of not taking medications New 1 (0.8) Chronic 2 (1.6) Special medication precautions New 4 (3.1) Chronic 7 (5.5) Reason for monitoring weight New 1 (0.8) Chronic 1 (0.8) How to monitor weight New 2 (1.6) Chronic 5 (2.4) When to call healthcare provider New 2 (1.6) Chronic 3 (2.3) Adjust diuretic dose New 24 (18.8) Chronic 19 (14.8) Fluid and sodium intake New 15 (11.7) Chronic 13 (10.2) Assessing of symptoms New 5 (3.9) Chronic 6 (4.7) Shortness of breath New 1 (0.8) Chronic 1 (0.8) Persistent cough New 9 (7.0) Chronic 11 (8.6)
Sometimes n (%)
Frequently/almost always n (%)
Mean score (SD)
14 (10.9) 43 (33.6)
101 (78.9) 73 (57.1)
4.34 (1.23) 3.74 (1.18)
10 (7.8) 29 (22.7)
106 (82.8) 87 (68.0)
4.46 (1.20) 4.0 (1.20)
3 (2.3) 10 (7.8)
116 (90.6) 110 (85.9)
4.64 (1.05) 4.43 (1.07)
1 (0.8) 4 (3.1)
117 (91.4) 116 (90.6)
4.71 (1.01) 4.62 (1.02)
12 (9.4) 24 (18.8)
106 (82.8) 92 (71.8)
4.44 (1.15) 4.06 (1.17)
15 (11.7) 31 (24.2)
97 (75.8) 80 (62.5)
4.13 (1.29) 3.75 (1.24)
19 (14.8) 39 (30.5)
91 (71.1) 68 (53.1)
3.98 (1.34) 3.57 (1.29)
6 (4.7) 28 (21.9)
114 (89) 92 (71.1
4.60 (1.04) 4.13 (1.14)
17 (13.3) 36 (28.1)
97 (75.8) 77 (59.4)
4.23 (1.20) 3.80 (1.15)
7 (5.5) 19 (14.8)
106 (82.8) 94 (73.5)
4.41 (1.27) 4.16 (1.31)
16 (12.5) 25 (19.5)
92 (71.9) 79 (61.7)
3.98 (1.32) 3.66 (1.28)
6 (4.7) 16 (12.5)
114 (89.1) 103 (80.5)
4.57 (1.04) 4.34 (1.12)
17 (13.3) 30 (23.4)
100 (78.2) 84 (65.6)
4.23 (1.15) 3.85 (1.15)
1 (0.8) 7 (5.5)
119 (93.0) 113 (88.3)
4.73 (0.97) 4.57 (1.05)
3 (2.3) 10 (7.8)
116 (90.6) 108 (84.4)
4.62 (1.06) 4.34 (1.12)
7 (5.5) 11 (8.6)
110 (85.9) 104 (81.3)
4.58 (1.10) 4.42 (1.17)
35 (27.3) 30 (23.4)
53 (41.4) 63 (49.2)
3.15 (1.65) 3.29 (1.61)
24 (18.8) 30 (23.4)
78 (60.9) 74 (57.9)
3.73 (1.53) 3.63 (1.44)
9 (7.0) 11 (8.6)
106 (82.8) 102 (79.7)
4.37 (1.21) 4.19 (1.22)
11 (8.6) 12 (9.4)
108 (84.4) 107 (83.6)
4.45 (1.15) 4.38 (1.08)
24 (18.8) 32 (25.0)
86 (67.2) 76 (59.4)
3.99 (1.35) 3.73 (1.31) (continued on next page)
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Table 3 (continued ) Content area
Almost never/infrequently n (%)
Sometimes n (%)
Frequently/almost always n (%)
Mean score (SD)
12 (9.4) 19 (14.8)
92 (71.9) 82 (64.1)
3.97 (1.39) 3.72 (1.37)
6 (4.7) 12 (9.4)
108 (84.3) 102 (79.7)
4.42 (1.20) 4.26 (1.23)
6 (4.7) 9 (7.0)
107 (83.6) 102 (79.7)
4.41 (1.25) 4.26 (1.32)
10 (7.8) 21 (16.4)
103 (80.4) 92 (71.7)
4.22 (1.27) 3.96 (1.27)
4 (3.1) 6 (4.7)
114 (89.1) 112 (87.5)
4.59 (1.11) 4.51 (1.13)
Assessing severity of lightheadedness New 15 (11.7) Chronic 18 (14.1) Assessing difficulty breathing while lying down New 5 (3.9) Chronic 6 (4.7) Follow-up appointment New 4 (3.1) Chronic 7 (5.5) Information to bring to appointment New 6 (4.7) Chronic 7 (5.4) Person to contact if symptoms develop New 3 (2.3) Chronic 3 (2.3)
established patient. Although spending more time with a newly diagnosed patient is ubiquitous in any clinical practice settings, no data exist to establish the ideal time/hours that should be spent by the nurse on a patient with a new diagnosis of HF or any other type of chronic illness. Furthermore, the nature or the quality of nurseepatient interaction (eg, education) and the correlation between nurses’ time and patient outcomes warrant exploration. Of note, the nurses’ years of experience are positively and significantly correlated with specific content (eg, alcohol intake and medications) covered in the patient education program. Although the strength of these relationships is somewhat weak (rs < 0.3), the results suggest that “experienced” nurses tend to place more emphasis on educating the patient about the importance of limiting alcohol intake, knowing precautionary measures related to taking cardiac medications, managing side effects of medications, and monitoring body weight. These findings are consistent with those of Albert et al.13 These correlations may be explained by the assumption that experienced nurses are practicing in a higher level of clinical competence (proficient or expert) in which they intuitively focus on intervening clinical phenomena that have utmost relevance or influence on patient outcomes.17 The disparity in the amount of time spent by these nurses on educating patients with new and chronic HF is a finding that warrants further study. Inadequate reinforcement of key information on patients with chronic HF may have a detrimental effect on their quality of life and prognosis. Reinforcement of information and education of families and caregivers may be particularly important in HF, in light of the complexity of the self-care regimen and the cognitive deficits that are common in this population.2 Areas that were less frequently addressed in chronic HF included the pathophysiology of HF, lifestyle modifications (diet and alcohol intake), medications (precautions and side effects), symptoms (cough and lightheadedness), and
Table 4 e Correlation of years worked as a nurse and patient education content areas (n [ 128) Education of newly diagnosed patients To limit alcohol intake Ways to manage side effects of medications Special precautions related to cardiac medications Monitoring of body weight
0.280y 0.183* 0.209* 0.221*
* Significance at the .05 level (2-tailed). y Significance at the .001 level (2-tailed).
health maintenance practices (knowledge to bring to appointment). Anecdotally, healthcare providers such as nurses and physicians in many clinical settings assume that patients with chronic HF “already know” their condition; thus, re-education or reinforcement of patients’ self-care knowledge, capabilities, and attitudes toward health maintenance is less likely to be emphasized until after patients’ readmission to the hospital. Despite the limitations inherent to any type of survey research like the present study, the findings reported offer beginning evidence about the assessment and education practice patterns of nurses in a variety of HF care settings throughout the United States. These findings support and add to the existing knowledge of the nurse’s role in specialized healthcare services.18 More research is needed to explore the rationale or explanatory variables (eg, nurses’ attitudes/culture, organizational infrastructure) of the disparity in time spent by nurses with patients with HF leading to evidence-based practice research. Finally, this study should heighten stakeholders’ awareness of the critical need to document the mechanisms by which a nurse’s role in assessment and education of patients with HF influences patient care outcomes (eg, mortality/ morbidity), which is paramount for evidence-based
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Table 5 e Heart failure assessment practices at each patient visit (n [ 128) Assessment practice
Almost never/infrequently n (%)
Review diagnosis New Chronic Illicit drug and alcohol use New Chronic Activity level New Chronic Ways to increase activity New Chronic Worsening signs or symptoms New Chronic Orthostatic B/P New Chronic Height New Chronic Weight New Chronic Measure BMI New Chronic Assessment of heart sounds New Chronic Assessment of heart rhythm New Chronic Assessment of lung sounds New Chronic
Sometimes n (%)
Frequently/almost always n (%)
Mean score (SD)
2 (1.6) 2 (1.6)
4 (3.1) 11 (8.6)
111 (86.7) 103 (80.5)
4.53 (1.06) 4.35 (1.13)
3 (2.4) 5 (3.9)
9 (7.0) 21 (16.4)
103 (80.5) 89 (69.6)
4.34 (1.12) 4.11 (1.19)
2 (1.6) 1 (0.8)
10 (7.8) 11 (8.6)
103 (80.5) 103 (80.5)
4.37 (1.11) 4.34 (1.09)
9 (7.0) 9 (7.0)
22 (17.2) 26 (20.3)
84 (65.6) 80 (62.5)
3.93 (1.28) 3.82 (1.22)
1 (0.8) 1 (0.8)
6 (4.7) 7 (5.5)
107 (83.3) 108 (84.4)
4.44 (1.14) 4.52 (0.99)
12 (9.4) 14 (10.9)
30 (23.4) 38 (29.7)
73 (57.1) 63 (49.3)
3.84 (1.24) 3.64 (1.25)
37 (28.9) 48 (37.5)
7 (5.5) 13 (10.2)
60 (55.5) 52 (40.6)
3.36 (1.73) 2.9 (1.71)
5 (3.9) 2 (1.6)
1 (0.8) 1 (0.8)
109 (85.2) 113 (88.3)
4.46 (1.18) 4.59 (0.98)
24 (18.8) 32 (25)
16 (12.5) 21 (16.4)
74 (57.8) 61 (47.6)
3.65 (1.59) 3.32 (1.60)
15 (11.8) 15 (10.2)
7 (5.5) 6 (4.7)
93 (72.6) 97 (75.8)
4.14 (1.39) 4.20 (1.33)
6 (4.7) 7 (5.5)
2 (1.6) 9 (7.0)
108 (84.4) 100 (78.2)
4.46 (1.16) 4.30 (1.21)
7 (5.5) 7 (5.5)
2 (1.6) 2 (1.6)
107 (83.6) 106 (82.8)
4.45 (1.20) 4.42 (1.20)
BMI, body mass index; B/P, blood pressure.
care and policy development. The AAHFN is pivotal in moving the science of HF nursing forward and should leverage the Institute of Medicine’s Recommendation19 charging nurses to transform the healthcare of this nation through research and leadership.
Conclusions Nurses are in a pivotal position to affect the outcomes of patients with HF. This study provides insight into the practice patterns of HF nurses. HF education and assessment practices were reported frequently for patients with newly diagnosed HF and those with chronic HF. Continued exploration of the HF nursing role is warranted and can serve to assist in advancing the emerging nursing specialty of chronic illness management.
References 1. Roger V, Lloyd-Jones D, Adams RJ, Berry JD, Brown TM, Carnethon MR, et al. Heart disease and stroke statisticse2011 update: a report from the American Heart Association. Circulation 2011;123:e18-209. 2. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, et al; Heart Failure Society of America. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16:e1-194. 3. Albert N. Evidence-based nursing care for patients with heart failure. AACN Adv Crit Car 2006;17:170-85. 4. Blue L, McMurray J. How much responsibility should heart failure nurses take? Eur J Heart Fail 2005;7:351-61. 5. Evangelista LS. What do we know about adherence and self-care? J Cardiovasc Nurs 2008;23:250. 6. van der Wal MH. Qualitative examination of compliance in heart failure patients in The Netherlands. Heart Lung 2010;39:121. 7. Rich MW. Management of heart failure in the elderly. Heart Fail Rev 2002;7:89.
h e a r t & l u n g 4 1 ( 2 0 1 2 ) 2 1 8 e2 2 5
8. Evangelista LS, Dracup K. A closer look at compliance research in heart failure patients in the last decade. Prog Cardiovasc Nurs 2000;15:97-103. 9. Giamouzis G. Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions. J Card Fail 2011;17:54. 10. Ditewig JB, Blok H, Havers J, van Veenendaal H. Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: a systematic review. Patient Educ Couns 2010;78:297-315. 11. Department of Health and Human Services. Application of incentives to reduce avoidable readmissions to hospitals. Federal Register 2008;73:23528-938. 12. Leveraging healthcare policy changes to decrease hospital 30-day readmission rates. Pennsylvania Patient Saf Advisory 2010;7:1-8. 13. Albert N, Collier S, Sumodi V, Wilkinson S, Hammel J, Vopat L, et al. Nurses’s knowledge of heart failure education principles. Heart Lung 2002;31:102-12. 14. Washburn S, Hornberger C, Klutman A, Skinner L. Nurses’ knowledge of heart failure education topics
15. 16.
17. 18.
19.
225
as reported in a small midwestern community hospital. J Cardiovasc Nurs 2005;20:215-20. Willette E, Surrells D, Davis L, Bush C. Nurses’ knowledge of heart failure self-management. Prog Cardiovasc Nurs 2007;22:190-5. Delaney C, Apostolidis B, Lachapelle L, Fortinsky R. Home care nurses’ knowledge of evidence-based education topics for management of heart failure. Heart Lung 2011;40:285-92. Benner P, Tanner C, Chesla C. Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. 2nd ed. New York, NY: Springer Publishing; 2009. Jessup M, Albert NM, Lanfear DE, Lindenfeld J, Massie BM, Walsh MN, et al. ACCF/AHA/HFSA 2011 survey results: current staffing profile of heart failure programs, including programs that perform heart transplant and mechanical circulatory support device implantation: a report of the ACCF Heart Failure and Transplant Committee, AHA Heart Failure and Transplantation Committee, and Heart Failure Society of America. J Am Coll Cardiol 2011;57:2115-24. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academy Press; 2011.
Practice patterns of heart failure nurses Marilyn A. Prasun, PhD, CCNS, FAHAa,*, Jesse Casida, PhD, RN, CCRN-CSCb, Jill Howie-Esquivel, PhD, RN, NPc, Bunny Pozehl, PhD, APRN-NPd, Beth Fahlberg, PhD, RNe, Cindy Johnson, MS, RN, CNSf, Juliet Mock, RN, MS, ACNS-BCg, Jill Quinn, PhD, RN, CS-ANPh, Karen Yehle, PhD, RNi, Linda Baas, PhD, RN, CHFN, ACNPj a
School of Nursing, Millikin University, Decatur, Illinois b Wayne State University, Detroit, Michigan c Acute Care Nurse Practitioner Program, Department of Physiological Nursing, University of California, San Francisco d University of Nebraska Medical Center, College of Nursing, Lincoln e School of Nursing, University of Wisconson-Madison f Red Deer Regional Heart Function Clinic, Red Deer, AL, Canada g ICU and Telemetry, Aurora Health Care, West Allis Medical Center, West Allis, Wisconsin h University of Rochester School of Nursing, Rochester, New York i School of Nursing, Purdue University, West Lafayette, Indiana j University of Cincinnati College of Nursing and Director of Research, The Christ Hospital, Cincinnati, Ohio
article info
abstract
Article history: Online 16 March 2012
Objective: Little is known about the practice patterns of nurses who work in the specialty of heart failure (HF). This specialty includes inpatient and outpatient sites for practice that incorporate intensive care to rehabilitation. The purpose of this study was to describe the current practice of nurses who are members of the American Association of Heart Failure Nurses (AAHFN).
Keywords: Heart failure nursing Heart failure patient education Practice patterns
Methods: A convenience sample of nurses attending the 2010 Annual Meeting of AAHFN was surveyed to determine current practice patterns. Results: The mean age of the nurses completing the survey was 48 years (standard deviation [SD] þ10), and the majority were white (85%) and female (98%). Approximately half (48%) completed a Master’s degree. The mean time worked as a nurse was 23 years (SD þ10), with a mean of 11 years (SD þ8.2) caring for patients with HF. Both HF education and physical assessment were reported to be provided frequently. Conclusion: This survey provides insight into the practice patterns of HF nurses. Continued monitoring of this role is warranted and can serve to assist the AAHFN in advancing HF knowledge and skills. Cite this article: Prasun, M. A., Casida, J., Howie-Esquivel, J., Pozehl, B., Fahlberg, B., Johnson, C., Mock, J., Quinn, J., Yehle, K., & Baas, L. (2012, MAY/JUNE). Practice patterns of heart failure nurses. Heart & Lung, 41(3), 218-225. doi:10.1016/j.hrtlng.2012.02.001.
* Corresponding author: Marilyn A. Prasun, PhD, CCNS, FAHA, Associate Professor, School of Nursing, Millikin University, Decatur, IL 62522. E-mail address: [email protected] (M. A. Prasun). 0147-9563/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.hrtlng.2012.02.001
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Heart failure (HF) is a chronic progressive disease and the most common hospital discharge diagnosis for patients aged more than 65 years.1 The number of people diagnosed with HF is increasing as our population continues to age and as medical advancements result in improved survival from cardiac problems. The Heart Failure Society of America’s 2010 Comprehensive Heart Failure Practice Guideline provides a strong evidence base for the importance of chronic HF management in promoting positive patient outcomes.2 Adherence to these guidelines of care, especially in relation to pharmacologic management of HF, has become an important indicator for quality of care. In addition to pharmacologic management, the 2010 Heart Failure Society of America Guideline emphasizes the need for comprehensive education and counseling to help patients, their families, and their caregivers in learning how to manage this complex chronic disease. Nurses play a key role in providing this needed education and counseling; however, little is known about actual practice patterns of nurses providing care to patients with HF. Albert3 notes that there is no uniformity in nursing care and no core nursing measures to guide the practice of nurses delivering care to patients with HF. There are varying roles and responsibilities of nurses providing care to patients with HF, yet there is little evidence to guide the necessary educational training required to adequately prepare nurses for the emerging role of the HF specialist nurse.4 The mission of the American Association of Heart Failure Nurses (AAHFN) is to unite professionals in the support and advancement of HF practice, education, and research to promote optimal patient outcomes. Key aspects of this organization include education on HF topics, including evidence-based practices and disease management, mentorship in clinical practice across the continuum of care, and facilitation of the conduct and translation of HF nursing research. Because little is known about actual practice patterns of nurses providing HF care, the AAHFN undertook a survey of nurses providing care to patients with HF to describe current patterns of nursing practice. HF is a chronic illness necessitating a complex daily self-care regimen including the management of numerous cardiovascular medications, daily monitoring of weight and symptoms, and ongoing adherence to dietary restrictions. The majority of individuals with this diagnosis are elderly with coexisting chronic illnesses and various types of functional limitations. Many individuals with HF have cognitive deficits or poor health literacy skills. Self-care behaviors are emphasized in the HF treatment guidelines as an essential element of HF disease management;2 however, nonadherence to the recommended HF self-care regimen accounts for approximately 50% of hospital readmissions in those with HF.5-10 In 2013, changes in the Medicare Prospective Payment System will reduce the reimbursement rates for care of patients with HF readmitted within 30 days after hospital discharge.11,12
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Therefore, it is important to understand the role of nursing in the prevention of hospital readmissions and the practice patterns of nurses who provide care to patients with HF. The literature describing practice patterns of HF nurses is limited. One study by Albert et al,13 which examined nurses’ knowledge of HF education principles (ie, diet, fluids and weight, signs or symptoms of worsening condition, medications, and exercise), found a mean knowledge score of 15.2 2.0 on a 20-item knowledge survey. Three additional studies using this same knowledge survey found similar results with a mean knowledge score for nurses ranging from 14.6 to 15.97.14-16 Education level was found to differ with registered nurses having a significantly higher mean knowledge score compared with licensed practical nurses,13 whereas a similar study found no differences in knowledge by educational level of the nurse.16 Experience level of nurses was found to make a significant difference in the study by Willette et al.15 Also, experience in the care of patients with cardiac disease resulted in higher knowledge scores in 2 studies.13,15 HF nurses had the highest scores, and they exceeded the knowledge scores of critical care, medical-surgical, or telemetry unit nurses.13 In the second study, cardiac care nurses had a higher mean knowledge score than telemetry nurses.15 Given the limited research in this area, it is important to gain more understanding of the practice role of the HF nurse and the impact this may have on the care of the patient with HF. The purpose of this study was to describe the practice patterns of nurses providing care to patients with HF. With nurses playing a key role in educating and supporting patients, families, and caregivers in the self-care skills that are needed to prevent rehospitalizations, it is important to more fully understand practice patterns to develop standards for the education and practice of HF nurses.
Materials and Methods The study used a descriptive cross-sectional survey design with a convenience sampling technique. After approval by Millikin University’s institutional review board, survey packets were distributed to 417 attendees at the 2010 annual meeting of the AAHFN. The survey packets contained a cover letter that explained the study and the questionnaire. Nurses interested in participating in the study were asked to complete the questionnaire and turn it in before the conclusion of the meeting. Responses were anonymous. Inclusion criteria for the study were registered nurses who reported providing HF education or care to patients. The study questionnaire was developed by HF nursing experts who were members of the AAHFN. It consisted of several demographic questions, 26 questions about educational practices, and 12 questions
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Table 1 e Demographic characteristics (n [ 128) Variable
Frequency
Age (y SD) Gender n (%) Male Female Ethnicity n (%) African American Caucasian Asian American Indian Other Nursing education n (%) Some college Associate degree
48.5 9.659
Not collected
2 (1.6) 126 (98.4)
Not collected
10 (7.8) 109 (85.2) 4 (3.1) 2 (1.6) 1 (0.8)
Not collected
Bachelor degree Master degree Doctoral degree Years worked as a nurse (mean SD) Practice setting n (%) Ambulatory clinic/office based Ambulatory clinic/hospital based Combined hospital/ambulatory Hospital Cardiac rehabilitation Home health
39 (30.5) 62 (48.4) 4 (3.1) 23.2 10.77
Years worked in HF (y SD) Percentage of patients with HF (mean SD)
10.9 8.21 73.87 29.5
13 (10.2) 9 (7.0)
16 (12.5) 24 (18.8) 22 (17.2) 54 (42.2) 1 (0.8) 3 (2.3)
AAHFN membership
Highest degree Associate degree Bachelor of Arts Bachelor of Science Bachelor of Science in Nursing Diploma Doctor of Nursing Practice Doctor of Nursing Science Master’s degree Medical Doctor Master’s in Public Health Master’s of Science Master’s of Science in Nursing Doctor of Philosophy Grand total
Total % 54 105 15 47 19 2 1 141 3 2 12 49 22 472
30 y Count of work_in Work_in HFP-in HFP-in-out HFP-out HFP-PP HFP-third industry PP-card PP-IM university Grand total Average 7e10 y N/A Not collected
Total % 100 88 76 12 8 10 24 2 22 342
HFP, heart failure program; IM, internal medicine; N/A, not available; PP, private practice.
about assessment practices. The educational and assessment practices were rated on the basis of the frequency of implementation in clinical practice using a 5-point scale ranging from almost never to almost always. Content validity of the tool was established through peer review by advanced practice and cardiovascular research nurses. Internal consistency of the items in the questionnaire was demonstrated by a Cronbach’s alpha of 0.96. Data collected from the questionnaire were analyzed and reported using descriptive statistics. Frequency distributions were used to organize the data, which are expressed as frequencies, percents, means, and standard deviations (SDs). Bivariate correlations were also calculated using Spearman’s rho 2-tailed significance
test. All statistical analysis was conducted using the Statistical Package for the Social Sciences version 17 (SPSS Inc, Chicago, IL). A total of 128 completed surveys were returned for a response rate of 31%.
Results Characteristics of the Nurses The mean age of the nurses who completed the survey was 48.5 10 years, and approximately half (48%) had completed a Master’s degree (Table 1). The average number of years employed as a nurse was 23.2 years,
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which is lower than the mean of 30 years for the AAHFN general population. The majority of nurses surveyed were employed in a hospital setting or a combined hospital and ambulatory care setting (59%). This is similar to the AAHFN general population, with 55% of members who report working in these settings. Nurses who completed the survey worked an average of 10 8 years in the HF setting. The majority of patients cared for by these nurses (73.8%) were diagnosed with HF. Nursing licensure was divided between Registered Nurse (56%) and Advanced Practice Registered Nurse (42%), with 41% of the Advanced Practice Registered Nurses credentialed to prescribe medications (Table 2). Nurses reported an average of 13 patient visits daily. Fifty percent of nurses reported spending 15 to 29 minutes reviewing patient information. Only half of participants (50%) reported employer support for outside continuing education. Few nurses reported working closely with a nurse who had published material (27%).
Table 2 e Nursing characteristics (n [ 128) Variable Nursing license n (%) RN APRN Licensed to prescribe n (%) Yes but do not prescribe Yes No Patients with HF managed daily (mean SD) Review of patient information n (%) 30 min to >1 h <15e29 min Employer supports education n (%) Yes Work closely with a published nurse n (%) Yes
Frequency 72 (56.3) 54 (42.2) 5 (3.9) 47 (36.7) 24 (18.8) 13.24 15.01
56 (43.7) 64 (50) 65 (50.8) 34 (26.6)
APRN, advanced practice registered nurse; RN, registered nurse.
Heart Failure Patient Education Practice Patterns
years of nursing experience was the topic of limiting alcohol intake (0.28; P ¼ .001).
Table 3 demonstrates the frequency with which the nurse participants reported providing HF education to their patients in various content areas. The nurses reported providing the most frequent patient education to patients with newly diagnosed HF and patients with chronic HF on the following topics (score > 4.0 for both patient groups): symptoms, particularly dyspnea and orthopnea, low-sodium diet, weight monitoring, medication purpose and importance of adherence, and information about contacting healthcare provider. The following educational areas were less frequently addressed, with scores < 4.0: pathophysiology (chronic HF), selecting low-sodium foods (chronic HF), limiting alcohol (new and chronic HF), common side effects (chronic HF), managing medication side effects (new and chronic HF), special medication precautions (chronic HF), adjusting diuretic medication (new and chronic HF), fluid and sodium intake (new and chronic HF), assessing a persistent cough (new and chronic HF), assessing lightheadedness (new and chronic HF), and information to bring to the follow-up appointment (chronic HF). The least frequent educational practice for patients with new HF and those with chronic HF was diuretic dose adjustment (mean 3.13 and 3.29, respectively). For those with chronic HF, nurses reported 3 other less frequent educational practices: limiting alcohol intake (mean 3.57), limiting fluid and sodium intake (mean 3.63), and managing medication side effects (mean 3.66). Certain educational practices were more common in nurses with more experience. Positive significant correlations were demonstrated between the number of years of nursing experience and several educational practices with patients with newly diagnosed HF (Table 4). The strongest correlation with the number of
Assessment Practice Patterns of Patients with Heart Failure Table 5 demonstrates the reported frequency of various types of assessments or examinations completed by nurses with each of their patients with HF. Participants reported performing the following assessments frequently with both those with new HF and those with chronic HF (mean scores 4.0; range 2.9-4.46): review of diagnosis, illicit drug and alcohol use, activity level, worsening signs or symptoms, weight, heart sounds, and rhythm and lung sounds. The following assessments were less frequently reported (<4.0) in those with newly diagnosed HF and those with chronic HF: ways to increase activity, orthostatic blood pressure, height, and measurement of body mass index. The least frequent type of assessment completed in patients with chronic HF was measurement of body mass index (mean 3.32).
Discussion These study findings describe the education and assessment practices of HF nurses in a variety of settings across the healthcare continuum nationwide. Survey respondents reported spending more time educating a new patient than established (chronic) patients. However, whether the patient with HF is newly diagnosed or chronically ill, the time spent reported by the survey respondents in assessing their patients during each visit appeared to be the same. Thus, it is expected that the nurse will spend more time educating a newly diagnosed patient than an
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Table 3 e Education practice patterns for patients with heart failure (n [ 128) Content area
Almost never/infrequently n (%)
Pathophysiology New 6 (4.6) Chronic 5 (3.9) Common symptoms New 5 (3.9) Chronic 5 (3.9) Effects of sodium New 2 (1.6) Chronic 1 (0.8) Limit dietary sodium New 2 (1.6) Chronic 1 (0.8) Read food labels New 3 (2.4) Chronic 4 (3.2) Selecting low sodium New 9 (7.0) Chronic 10 (7.8) Limit alcohol New 10 (7.8) Chronic 13 (10.2) Purpose of medication New 1 (0.8) Chronic 1 (0.8) Common side effects New 6 (4.7) Chronic 6 (4.7) When to call healthcare New 8 (6.2) Chronic 8 (6.2) Manage medication side effects New 13 (10.2) Chronic 17 (13.3) Consequence of not taking medications New 1 (0.8) Chronic 2 (1.6) Special medication precautions New 4 (3.1) Chronic 7 (5.5) Reason for monitoring weight New 1 (0.8) Chronic 1 (0.8) How to monitor weight New 2 (1.6) Chronic 5 (2.4) When to call healthcare provider New 2 (1.6) Chronic 3 (2.3) Adjust diuretic dose New 24 (18.8) Chronic 19 (14.8) Fluid and sodium intake New 15 (11.7) Chronic 13 (10.2) Assessing of symptoms New 5 (3.9) Chronic 6 (4.7) Shortness of breath New 1 (0.8) Chronic 1 (0.8) Persistent cough New 9 (7.0) Chronic 11 (8.6)
Sometimes n (%)
Frequently/almost always n (%)
Mean score (SD)
14 (10.9) 43 (33.6)
101 (78.9) 73 (57.1)
4.34 (1.23) 3.74 (1.18)
10 (7.8) 29 (22.7)
106 (82.8) 87 (68.0)
4.46 (1.20) 4.0 (1.20)
3 (2.3) 10 (7.8)
116 (90.6) 110 (85.9)
4.64 (1.05) 4.43 (1.07)
1 (0.8) 4 (3.1)
117 (91.4) 116 (90.6)
4.71 (1.01) 4.62 (1.02)
12 (9.4) 24 (18.8)
106 (82.8) 92 (71.8)
4.44 (1.15) 4.06 (1.17)
15 (11.7) 31 (24.2)
97 (75.8) 80 (62.5)
4.13 (1.29) 3.75 (1.24)
19 (14.8) 39 (30.5)
91 (71.1) 68 (53.1)
3.98 (1.34) 3.57 (1.29)
6 (4.7) 28 (21.9)
114 (89) 92 (71.1
4.60 (1.04) 4.13 (1.14)
17 (13.3) 36 (28.1)
97 (75.8) 77 (59.4)
4.23 (1.20) 3.80 (1.15)
7 (5.5) 19 (14.8)
106 (82.8) 94 (73.5)
4.41 (1.27) 4.16 (1.31)
16 (12.5) 25 (19.5)
92 (71.9) 79 (61.7)
3.98 (1.32) 3.66 (1.28)
6 (4.7) 16 (12.5)
114 (89.1) 103 (80.5)
4.57 (1.04) 4.34 (1.12)
17 (13.3) 30 (23.4)
100 (78.2) 84 (65.6)
4.23 (1.15) 3.85 (1.15)
1 (0.8) 7 (5.5)
119 (93.0) 113 (88.3)
4.73 (0.97) 4.57 (1.05)
3 (2.3) 10 (7.8)
116 (90.6) 108 (84.4)
4.62 (1.06) 4.34 (1.12)
7 (5.5) 11 (8.6)
110 (85.9) 104 (81.3)
4.58 (1.10) 4.42 (1.17)
35 (27.3) 30 (23.4)
53 (41.4) 63 (49.2)
3.15 (1.65) 3.29 (1.61)
24 (18.8) 30 (23.4)
78 (60.9) 74 (57.9)
3.73 (1.53) 3.63 (1.44)
9 (7.0) 11 (8.6)
106 (82.8) 102 (79.7)
4.37 (1.21) 4.19 (1.22)
11 (8.6) 12 (9.4)
108 (84.4) 107 (83.6)
4.45 (1.15) 4.38 (1.08)
24 (18.8) 32 (25.0)
86 (67.2) 76 (59.4)
3.99 (1.35) 3.73 (1.31) (continued on next page)
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Table 3 (continued ) Content area
Almost never/infrequently n (%)
Sometimes n (%)
Frequently/almost always n (%)
Mean score (SD)
12 (9.4) 19 (14.8)
92 (71.9) 82 (64.1)
3.97 (1.39) 3.72 (1.37)
6 (4.7) 12 (9.4)
108 (84.3) 102 (79.7)
4.42 (1.20) 4.26 (1.23)
6 (4.7) 9 (7.0)
107 (83.6) 102 (79.7)
4.41 (1.25) 4.26 (1.32)
10 (7.8) 21 (16.4)
103 (80.4) 92 (71.7)
4.22 (1.27) 3.96 (1.27)
4 (3.1) 6 (4.7)
114 (89.1) 112 (87.5)
4.59 (1.11) 4.51 (1.13)
Assessing severity of lightheadedness New 15 (11.7) Chronic 18 (14.1) Assessing difficulty breathing while lying down New 5 (3.9) Chronic 6 (4.7) Follow-up appointment New 4 (3.1) Chronic 7 (5.5) Information to bring to appointment New 6 (4.7) Chronic 7 (5.4) Person to contact if symptoms develop New 3 (2.3) Chronic 3 (2.3)
established patient. Although spending more time with a newly diagnosed patient is ubiquitous in any clinical practice settings, no data exist to establish the ideal time/hours that should be spent by the nurse on a patient with a new diagnosis of HF or any other type of chronic illness. Furthermore, the nature or the quality of nurseepatient interaction (eg, education) and the correlation between nurses’ time and patient outcomes warrant exploration. Of note, the nurses’ years of experience are positively and significantly correlated with specific content (eg, alcohol intake and medications) covered in the patient education program. Although the strength of these relationships is somewhat weak (rs < 0.3), the results suggest that “experienced” nurses tend to place more emphasis on educating the patient about the importance of limiting alcohol intake, knowing precautionary measures related to taking cardiac medications, managing side effects of medications, and monitoring body weight. These findings are consistent with those of Albert et al.13 These correlations may be explained by the assumption that experienced nurses are practicing in a higher level of clinical competence (proficient or expert) in which they intuitively focus on intervening clinical phenomena that have utmost relevance or influence on patient outcomes.17 The disparity in the amount of time spent by these nurses on educating patients with new and chronic HF is a finding that warrants further study. Inadequate reinforcement of key information on patients with chronic HF may have a detrimental effect on their quality of life and prognosis. Reinforcement of information and education of families and caregivers may be particularly important in HF, in light of the complexity of the self-care regimen and the cognitive deficits that are common in this population.2 Areas that were less frequently addressed in chronic HF included the pathophysiology of HF, lifestyle modifications (diet and alcohol intake), medications (precautions and side effects), symptoms (cough and lightheadedness), and
Table 4 e Correlation of years worked as a nurse and patient education content areas (n [ 128) Education of newly diagnosed patients To limit alcohol intake Ways to manage side effects of medications Special precautions related to cardiac medications Monitoring of body weight
0.280y 0.183* 0.209* 0.221*
* Significance at the .05 level (2-tailed). y Significance at the .001 level (2-tailed).
health maintenance practices (knowledge to bring to appointment). Anecdotally, healthcare providers such as nurses and physicians in many clinical settings assume that patients with chronic HF “already know” their condition; thus, re-education or reinforcement of patients’ self-care knowledge, capabilities, and attitudes toward health maintenance is less likely to be emphasized until after patients’ readmission to the hospital. Despite the limitations inherent to any type of survey research like the present study, the findings reported offer beginning evidence about the assessment and education practice patterns of nurses in a variety of HF care settings throughout the United States. These findings support and add to the existing knowledge of the nurse’s role in specialized healthcare services.18 More research is needed to explore the rationale or explanatory variables (eg, nurses’ attitudes/culture, organizational infrastructure) of the disparity in time spent by nurses with patients with HF leading to evidence-based practice research. Finally, this study should heighten stakeholders’ awareness of the critical need to document the mechanisms by which a nurse’s role in assessment and education of patients with HF influences patient care outcomes (eg, mortality/ morbidity), which is paramount for evidence-based
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Table 5 e Heart failure assessment practices at each patient visit (n [ 128) Assessment practice
Almost never/infrequently n (%)
Review diagnosis New Chronic Illicit drug and alcohol use New Chronic Activity level New Chronic Ways to increase activity New Chronic Worsening signs or symptoms New Chronic Orthostatic B/P New Chronic Height New Chronic Weight New Chronic Measure BMI New Chronic Assessment of heart sounds New Chronic Assessment of heart rhythm New Chronic Assessment of lung sounds New Chronic
Sometimes n (%)
Frequently/almost always n (%)
Mean score (SD)
2 (1.6) 2 (1.6)
4 (3.1) 11 (8.6)
111 (86.7) 103 (80.5)
4.53 (1.06) 4.35 (1.13)
3 (2.4) 5 (3.9)
9 (7.0) 21 (16.4)
103 (80.5) 89 (69.6)
4.34 (1.12) 4.11 (1.19)
2 (1.6) 1 (0.8)
10 (7.8) 11 (8.6)
103 (80.5) 103 (80.5)
4.37 (1.11) 4.34 (1.09)
9 (7.0) 9 (7.0)
22 (17.2) 26 (20.3)
84 (65.6) 80 (62.5)
3.93 (1.28) 3.82 (1.22)
1 (0.8) 1 (0.8)
6 (4.7) 7 (5.5)
107 (83.3) 108 (84.4)
4.44 (1.14) 4.52 (0.99)
12 (9.4) 14 (10.9)
30 (23.4) 38 (29.7)
73 (57.1) 63 (49.3)
3.84 (1.24) 3.64 (1.25)
37 (28.9) 48 (37.5)
7 (5.5) 13 (10.2)
60 (55.5) 52 (40.6)
3.36 (1.73) 2.9 (1.71)
5 (3.9) 2 (1.6)
1 (0.8) 1 (0.8)
109 (85.2) 113 (88.3)
4.46 (1.18) 4.59 (0.98)
24 (18.8) 32 (25)
16 (12.5) 21 (16.4)
74 (57.8) 61 (47.6)
3.65 (1.59) 3.32 (1.60)
15 (11.8) 15 (10.2)
7 (5.5) 6 (4.7)
93 (72.6) 97 (75.8)
4.14 (1.39) 4.20 (1.33)
6 (4.7) 7 (5.5)
2 (1.6) 9 (7.0)
108 (84.4) 100 (78.2)
4.46 (1.16) 4.30 (1.21)
7 (5.5) 7 (5.5)
2 (1.6) 2 (1.6)
107 (83.6) 106 (82.8)
4.45 (1.20) 4.42 (1.20)
BMI, body mass index; B/P, blood pressure.
care and policy development. The AAHFN is pivotal in moving the science of HF nursing forward and should leverage the Institute of Medicine’s Recommendation19 charging nurses to transform the healthcare of this nation through research and leadership.
Conclusions Nurses are in a pivotal position to affect the outcomes of patients with HF. This study provides insight into the practice patterns of HF nurses. HF education and assessment practices were reported frequently for patients with newly diagnosed HF and those with chronic HF. Continued exploration of the HF nursing role is warranted and can serve to assist in advancing the emerging nursing specialty of chronic illness management.
References 1. Roger V, Lloyd-Jones D, Adams RJ, Berry JD, Brown TM, Carnethon MR, et al. Heart disease and stroke statisticse2011 update: a report from the American Heart Association. Circulation 2011;123:e18-209. 2. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, et al; Heart Failure Society of America. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16:e1-194. 3. Albert N. Evidence-based nursing care for patients with heart failure. AACN Adv Crit Car 2006;17:170-85. 4. Blue L, McMurray J. How much responsibility should heart failure nurses take? Eur J Heart Fail 2005;7:351-61. 5. Evangelista LS. What do we know about adherence and self-care? J Cardiovasc Nurs 2008;23:250. 6. van der Wal MH. Qualitative examination of compliance in heart failure patients in The Netherlands. Heart Lung 2010;39:121. 7. Rich MW. Management of heart failure in the elderly. Heart Fail Rev 2002;7:89.
h e a r t & l u n g 4 1 ( 2 0 1 2 ) 2 1 8 e2 2 5
8. Evangelista LS, Dracup K. A closer look at compliance research in heart failure patients in the last decade. Prog Cardiovasc Nurs 2000;15:97-103. 9. Giamouzis G. Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions. J Card Fail 2011;17:54. 10. Ditewig JB, Blok H, Havers J, van Veenendaal H. Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: a systematic review. Patient Educ Couns 2010;78:297-315. 11. Department of Health and Human Services. Application of incentives to reduce avoidable readmissions to hospitals. Federal Register 2008;73:23528-938. 12. Leveraging healthcare policy changes to decrease hospital 30-day readmission rates. Pennsylvania Patient Saf Advisory 2010;7:1-8. 13. Albert N, Collier S, Sumodi V, Wilkinson S, Hammel J, Vopat L, et al. Nurses’s knowledge of heart failure education principles. Heart Lung 2002;31:102-12. 14. Washburn S, Hornberger C, Klutman A, Skinner L. Nurses’ knowledge of heart failure education topics
15. 16.
17. 18.
19.
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as reported in a small midwestern community hospital. J Cardiovasc Nurs 2005;20:215-20. Willette E, Surrells D, Davis L, Bush C. Nurses’ knowledge of heart failure self-management. Prog Cardiovasc Nurs 2007;22:190-5. Delaney C, Apostolidis B, Lachapelle L, Fortinsky R. Home care nurses’ knowledge of evidence-based education topics for management of heart failure. Heart Lung 2011;40:285-92. Benner P, Tanner C, Chesla C. Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. 2nd ed. New York, NY: Springer Publishing; 2009. Jessup M, Albert NM, Lanfear DE, Lindenfeld J, Massie BM, Walsh MN, et al. ACCF/AHA/HFSA 2011 survey results: current staffing profile of heart failure programs, including programs that perform heart transplant and mechanical circulatory support device implantation: a report of the ACCF Heart Failure and Transplant Committee, AHA Heart Failure and Transplantation Committee, and Heart Failure Society of America. J Am Coll Cardiol 2011;57:2115-24. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academy Press; 2011.