SOLUTION: NSG 3029 South University Symptom Management and Hospital Readmission Worksheet

NSG3029 W5 Project
Research Template
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Week 5 Template
Check the correct method used in your article
Quantitative
Qualitative
Identify the research
problem.
Identify the research purpose.
Summarize the literature
review.
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framework or theoretical
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future nursing practice.
Apply the research to
your nursing practice.
Crit Care Nurs Q
Vol. 42, No. 1, pp. 81–88
c 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright
Symptom Management and
Hospital Readmission in Heart
Failure Patients
A Qualitative Study From Portugal
Joana Pereira Sousa, MNSc, RN; Miguel Santos, PhD
This article reports a study aimed at identifying the factors that result in hospital readmissions for
patients with heart failure. The high rates of readmission are often due to a lack of knowledge
about symptoms and signs of disease progression, and these Portuguese nurses believed that readmissions could be decreased through disease management programs in which patients assumed
a more active role in self-care. A study was designed to identify broad categories of problems
that lead Portuguese patients with heart failure to be readmitted to hospital. Semistructured interviews were conducted, recorded, and submitted for content analysis, revealing 3 main categories
for targeting: health management, behavioral management, and psychological support. This study
revealed that patients with heart failure seem to struggle with management of multiple treatment
regimens during the long course of their chronic illness. Based on these interviews, authors conclude that a disease management program be tailored expressly for the Portuguese culture and
their lifestyle. Key words: disease management, heart failure, hospital readmission, self-care
behavior
H
EART FAILURE (HF) is considered a
major public health problem worldwide1,2 and is expected to continue to
increase in coming years.1,3 HF is a lifethreatening event with fast onset,3 characterized by fatigue, breathlessness at rest or
Author Affiliations: Instituto de Ciências da Saúde,
Universidade Católica Portuguesa, Porto, Portugal
and Cardiology Unit/Heart Failure Intensive Care
Unit, Centro Hospitalar e Universitário de Coimbra,
Portugal (Ms Sousa); and Centro de Investigação
Interdisciplinar em Saúde – Instituto Ciências da
Saúde, Universidade Católica Portuguesa, Porto,
Portugal (Dr Santos).
The authors thank Editage (www.editage.com) for
English language editing.
The authors have disclosed that they have no significant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Joana Pereira Sousa, MNSc, RN, Cardiology Unit/Heart Failure Intensive Care Unit, Floor 3,
Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
(jomorango@gmail.com).
DOI: 10.1097/CNQ.0000000000000241
on exertion, and fluid retention occurring
mostly in the legs, ankles, and lungs.3,4
Furthermore, it is associated with frequent
hospital readmission, poor quality of life,
high mortality, and financial problems.5-8
It has been previously reported that about
50% of the population in industrialized countries is at risk of being hospitalized with HF.9
In addition, these same patients are likely to
be readmitted to the health system within
6 months after discharge,9 leading to a health
system burden.10 Some of the main causes
for readmission include premature discharge
and educational and follow-up inefficacy, suggesting that about half of these readmissions
could potentially be prevented.6,9,11 However, it is also possible that because of the
overwhelming level of responsibility regarding disease management (eg, medication management, exercise, resting of the legs, and eating habits) and difficulty in coping with the
multiple lifestyle changes required by HF, it is
difficult for them to engage in recommended
self-care behaviors.11
81
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
82
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2019
Self-care can have different meanings,
depending on the underlying theory.4,12
According to Riegel et al,4 self-care is the
decision-making process through which patients adopt specific behaviors to maintain physical stability (eg, monitoring HF
symptoms and therapeutic adherence) and
promptly react when symptoms are first detected. In the context of HF, these self-care
behaviors include adherence to the treatment
regimen, symptom monitoring, and prevention of heart deterioration.6,9,11,13,14 In patients with HF, self-care behaviors include detection of initial symptoms of the disease,
which allows them to make appropriate decisions about the best course of action regarding the implementation of proper treatment strategies.4,11 Riegel and colleagues11
further subdivided self-care into 2 additional
subtypes relevant to HF: self-care maintenance (which involves the choice of behaviors that tend to maintain physiologic stability) and self-care management (which includes a response to symptoms when they
first occur). Based on these 2 types of selfcare for HF management, patients may benefit from a 2-stage disease management program (DMP). In this DMP, patients (1) would
be able to start a decision-making process and
(2) would learn about the disease to identify
health problems and implement strategies to
solve them.15 According to the European Society of Cardiology guidelines for HF, such a
program should be provided in specialized HF
clinics with health professionals (eg, nurses,
physicians, pharmacists, and physical therapists) who are experts in this disease, with
the goal of developing specific HF care and
better outcomes.16,17
Although a previous study described the
main categories of problems for a sample of
patients from the United States,18 it is not
clear whether the same categories are present
in patients with HF from a southern European
country. In this study, the aim was to identify broad categories of problems that lead
Portuguese patients with HF to be readmitted to hospital, through analyses of semistructured interviews with patients with HF, car-
diologists, and expert nurses in a cardiology
ward. Based on these interviews, the first intent was to determine why patients with HF
do not contact their doctors or nurses when
symptoms first start (eg, weight gain, body
edema, or tiredness) and second, what health
care providers can do to meet patients’ needs
to engage them and change their behaviors.
METHODS
Design
This study was based on the framework of complex interventions proposed by the Medical Research Council
(MRC),19 which involves 4 phases: development, feasibility/piloting, evaluation, and
implementation.19,20 This study represents
primary research, which is part of phase
I (development) of the MRC framework,
using qualitative methodology. According
to the MRC.19 complex interventions allow
a clear and detailed description of all the
components of the experimental and control
interventions, providing a better understanding of the feasibility and effectiveness, as well
as optimizing dissemination and implementation of the experimental intervention. This
initial qualitative study allowed identification
of themes to be developed based on interviews with participants. In combination with
a systematic literature review, these themes
form the basis of a complex intervention to
be later implemented in a DMP. Therefore,
this study was designed to ensure that the
future choice of intervention would be based
on participants’ needs, rather than on the
researcher’s opinion or preference. In short,
the present study constitutes phase I of a
larger study that will be later evaluated in a
DMP for patients with HF.19,20
Sample
For this study, a convenience sample was
composed of 5 patients (Pt) hospitalized for
primary HF, 2 cardiologist physicians (C), and
3 nurses (N) who were experts in HF, from
a cardiology ward in Centro Hospitalar e
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Hospital Readmission in Heart Failure
83
Universitário de Coimbra, Portugal. Inclusion
criteria for patients were being older than
18 years, admitted into an HF cardiac ward,
and consented to be interviewed for this
study. Patients were not currently involved in
a structured DMP; thus, they were receiving
little information about what to do if an escalation of symptoms was detected.
primary researcher. After transcription, key
terms were identified, and themes emerged.
The coding process was reanalyzed 3 times,
wherein the main categories were narrowed
down from 4 to 3. Key terms were then reanalyzed to track variability of themes. Lastly, key
terms were grouped into main categories.
Procedure
All participants provided written informed
consent for the interviews. The Committee
for Ethics of Centro Hospitalar e Universitário
de Coimbra approved this study. This investigation also followed the principles defined in
the Declaration of Helsinki.21
All participants were interviewed and approached face-to-face by the primary researcher (J.P.S.), a registered nurse in this
setting, in a separate room of the cardiology ward of Centro Universitário e Hospitalar de Coimbra. The cardiologist physicians
and nurses who participated were coworkers
of the primary researcher. The patients interviewed had been admitted with chronic HF,
had an acute escalation in their symptoms,
were available at the time of the interview,
and consented to be interviewed for this
study. At the time of the interview, the primary researcher and the patients did not have
an existing relationship. The interviews took
place during a 2-month period and lasted approximately 30 minutes each. The semistructured interviews were recorded and followed
by verbatim transcription.
Analysis
Content analysis was conducted using the
NVivo 10 program for qualitative data, by the
Ethical considerations
RESULTS
Analysis of the semistructured interviews
revealed 3 main categories: health management, behavior management, and support
received, which can be seen in the Table.
Health management
The category health management was related to patients’ knowledge about HF signs
and symptoms. It also included the ability to
follow the therapeutic regimen as specified
by health care providers (eg, prescriptions),
the ability to adopt a specific lifestyle, and
knowledge about when to contact the physician. Examples of this include the following:
“I know I must walk a little bit every day.
Table. Emergent Themes From Semistructured Interviews
Emergent Themes
Health management
Subthemes
Contact doctor when feeling worse
Follow providers’ prescriptions (eg,
exercise and diet)
Knowledge about heart failure signs
and symptoms
Behavior management Lack of knowledge
Consciousness of lifestyle errors
Therapeutic noncompliance
Support received
Longer and regular clinic visits
Home visits
Family and patient education
Telephone follow-up
Participants
Patients (Pt1, Pt2, Pt3, and Pt4)
Cardiologist physician (C1)
Patients (Pt1, Pt2, Pt3, Pt4, and Pt5)
Cardiologist physician (C1 and C2)
Nurses (N1, N2, and N3)
Patients (Pt3, Pt4, and Pt5)
Cardiologist physician (C1 and C2)
Nurses (N1, N2, and N3)
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
84
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2019
I should drink about a liter of water ( . . . ) and
not eat salty food and avoid sugars” (Pt1), and
“Yes, I am careful at home, with the amount
of water and food” (Pt2). During interviews,
it was found that, of 5 patients, 4 mentioned
information related to symptom identification
(such as symptoms indicative of a worsening
health condition). For example, “I am here
because of shortness of breath and swollen
legs” (Pt4) or “I walked two or three steps
and became distressed” (Pt1). Most importantly, these patients were not only able to
identify these signs and symptoms but also
able to decide when they should contact
their physician. For example, “then, I telephoned my cardiologist” (Pt1). In contrast,
health professionals generally did not mention these symptoms in their interviews. Only
one physician—an exception to this trend—
mentioned the following: “to seek medical
advice and contact the medical and nursing
teams when there is a worsening of symptoms, for example, daily weight (if there is
weight gain) or starting to become tired or
short of breath” (C1). However, neither the
other physician nor the nurses mentioned
these symptoms in their interviews (see the
Table).
Behavior management
This theme showed a general lack of
knowledge of the signs and symptoms of the
disease. For example, patients mentioned
that “at medical consultation, the physician
told me to stay and be admitted to hospital
because of my health complaints (tiredness
and fatigue)” (Pt3) and that “I came to
the hospital only when I couldn’t sleep
anymore, I slept sitting with several pillows
under my back. My legs were swollen . . . ”
(Pt3). In addition, patients also mentioned
being self-aware of not complying with the
required lifestyle. For example, one patient
mentioned, “In reality, I should fulfill the water restriction, but I drink much more than is
recommended. I struggle meeting this kind of
guideline because I have had this problem for
so long” (Pt3). Meanwhile, another patient
mentioned that despite having the intent to
follow the health worker’s suggestions, working far from home made it difficult to change
behaviors related to self-care: “I have been
working abroad for 24 years and it is really
hard to follow any kind of guideline because
I have lunch in restaurants and at night I eat
whatever I have. I come home every two
weeks” (Pt3). One patient also mentioned
not obeying health care instructions, despite
being aware that this would most likely lead
him to hospital readmission: “sometimes I
drink wine that I should not drink. Also [I
drink] beer and should be more careful with
the food [I eat]” (Pt5).
Analysis of physicians’ interviews suggested that changing self-care behaviors
might be hard for patients. One physician
mentioned that “there are people for which
the intervention is not effective, even with
regular information sessions. This is either
because they do not have any nearby family, or they live alone, or they are alcoholics”
(C1). This physician concluded that “the
biggest cause of heart failure decompensation is non-compliance.” The interviews with
these physicians also suggested that “patients
do not comply with the pharmacological regimen and fluid restriction” (C2). These patients also were not following a proper “diet,
not exercising, in other words, not living a
lifestyle adjusted to his chronic disease” (C1).
Analysis of nurses’ interviews revealed that
behavior management also included “therapeutic non-compliance” (N2), and “not being
careful with food regimen and fluid and alcohol intake” (N3). For nurses, the main factor in “getting worse is the failure in fluid intake” (N1). They mention that, even though
patients received information about their illness and about decisions to make when first
signs of complications were detected, “after a
week or two they start to forget the education
received, if not recalled” (N1). Other nurses
mentioned that patients “have the notion that
they should not drink large amounts of liquids, should not drink alcohol, and should not
smoke. However, they are not yet motivated.
There is some reason why they keep engaging
in inappropriate behaviors” (N1). In addition,
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Hospital Readmission in Heart Failure
these nurses also mentioned that some patients may think that because they are “taking the medication, they are controlled and
make food mistakes,” apparently, due to “lack
of knowledge” (N2).
Support received
In this category, both patients and health
care providers mentioned the importance
of having regular visits. For example, one of
the patients explicitly mentioned, “Instead
of making one annual visit to the physician
(in the clinic), these should take place more
regularly. I am willing to come to the hospital
more often and be assessed by a nurse”
(Pt5). In the interviews, both physicians and
nurses suggested that, if a regular visit to the
clinic was not feasible, a telephone follow-up
should take place. According to the physicians and nurses, health professionals should
be able to “periodically ( . . . ) telephone our
patients to determine if they are following
the therapeutic regimen or not, and how
their weight is evolving. This is a way to
detect heart failure decompensation” (C2);
or as a nurse put it, “if they do not remember
( . . . ) I think there should be an effort from
us (healthcare providers), with a telephone
call, because eventually all the information
taught will be forgotten. Then there will
be the temptation (of increasing fluid intake . . . ), they will start to decompensate,”
(N3) and eventually end up being admitted
to emergency care or the intensive care
unit.
As a possible solution for health and behavior management, physicians and nurses
suggested implementing a structured educational program. According to one nurse,
patients should receive “several educational
sessions, which are fundamental; we should
implement educational sessions in all clinic
visits, because they (patients) need this kind
of education” (N2). These sessions should
include reminding the patient about illness
progression and necessary lifestyle changes.
As one physician put it, “first of all, the
concept of heart failure as a disease must be
well clarified. This includes why a patient
85
has heart failure and what he/she can do to
adjust his/her daily life” (C1). In addition,
knowing when to take specific actions was
also considered a key feature, as mentioned
by a nurse: “If a patient starts to feel shortness
of breath or tiredness, this patient should not
stay at home, because staying at home will
probably worsen the health problem, and the
patient will eventually arrive (at hospital) in
a deteriorated condition” (N3).
During these interviews, it was also noticed that some patients knew they should adhere to health care providers’ prescriptions
to avoid hospital admissions: “what counts is
to meet the most guidelines” (Pt5); however,
unfortunately, patients tend to forget if not
reminded.
DISCUSSION
Self-care is a decision process through
which the patient has the ability to
choose between different health-influencing
behaviors.2,3 This process helps patients
maintain an adequate physical status (monitoring signs and symptoms and therapeutic
regimen adherence), and prompts an early
and adequate response when necessary.4,11
In HF, self-care is believed to be relevant
because previous studies have demonstrated
that DMPs run by a multidisciplinary team
can lead to improvements in self-care, …
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