wpsaliskicrnp.weebly.comwpsaliskicrnp.weebly.com/uploads/2/7/7/8/27788745/e… · Web viewImproving Self-Management of Heart Failure with APN Education . William P Saliski . Auburn

Improving Self-Management of Heart Failure with APN Education


William P Saliski

Auburn University

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Abstract

A critical financial goal in healthcare today is the decrease in amount of hospital

readmissions due to congestive heart failure (CHF) coupled with an increase in knowledge

and self-management in CHF patients. The number of Americans living with CHF is

astronomical and continually growing at an exponential rate. Evidence-based research has

shown that teaching done on CHF prior to hospital discharge is barely adequate and leads

to readmissions. Therefore, the teach-back method will be a strategy of interest to help

counteract these growing numbers. This method will be evaluated to determine

knowledge retention regarding CHF and improvement in overall quality of life (QOL). In

patients with newly diagnosed CHF, the teach-back method will be used which

incorporates information reiteration. During this teaching, people will be given

information on medications, daily weights, diet, exercise, and signs and symptoms of CHF

exacerbation. In order to see if a change has been made, pre and post teaching

questionnaires will be given. After discharge a follow-up questionnaire will check for

retention and to determine improvement in QOL. The collected data will be analyzed using

SPSS and evaluated with descriptive statistics and dependent t-tests. Out of 18 patients

invited to participate, 15 consented to participate in the project. Comparison between the

pre and post questionnaires showed an almost 50% improvement in each section of the

questionnaire. The follow up questionnaire showed that there was not a drastic affect in

QOL from the CHF and that the patients overall scores remained in the lower part of the

scoring bracket. The use of the teach-back method during discharge teaching has shown

improvements in knowledge retention and comprehension. When involving the patient

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more during teaching, they can comprehend what they physically need to do outside the

hospital.

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Improving Self-Management of Heart with APN Education

As the population continues to grow older so does the rate at which one is diagnosed or

readmitted into a hospital with congestive heart failure (CHF). There are almost five million

Americans living with CHF and nearly 550,000 people are newly diagnosed each year (Nash,

Reifsnyder, Fabius, & Pracilio,., 2011). In the United States alone CHF is the leading cause of

death accounting for 287,000 a year and the cost for treatment can exceed $475 billion (Nash et

al., 2011). As individuals are diagnosed with CHF their quality of life will never be the same

unless something can be done to promote a healthy lifestyle. If these people do not take any

action, then half of the newly diagnosed will die within five years of when the diagnosis of this

chronic condition is made. Treatment of chronic conditions such as CHF account for almost 80

percent of healthcare spending in the United States and with the aging population increasing, a

change is needed to help reverse this trend (Nash et al., 2011).

CHF is one of the most difficult chronic conditions to manage and requires multiple

interdisciplinary members including physicians, nurses, and educators to orchestrate optimal

care. Medications and lifestyle habits are some of the things that need to be managed by this

team as they can change with the symptoms that one is experiencing. One way of managing

symptoms and lifestyle factors is through self-management. Self-management allows a patient

to play a part in his or her own care and helps promote a higher quality life. This is a good way

to help care for a chronic condition, but can be very hard with having to educate the patient on

symptoms to watch for, medications to be taken, and diet regimens to be fulfilled. A person with

heart failure can take up to at least three different kinds of medications at different intervals in

the day; therefore, without the proper knowledge important factors may be left out or forgotten,

which can lead to an exacerbation. As Nash and others (2011) state, “Sixty-four percent of

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Kathy Ellison, 04/29/12,

Put all first time


Symptoms or self-management behaviors. You can’t manage another’s habits.


Wording awkward – QOL is at risk and healthy lifestyle promotion is imperative


hospital admissions for congestive heart failure are associated with failure to take prescribed

medications…” (p.69). This is where a change needs to be made and the idea of a project needs

to be formed as to educate heart failure patients on what can be done to help improve the quality

of life.

The premise for the population, intervention, comparison, and outcome, (PICO) question

for this project is the increasing hospital readmission rate due to CHF exacerbations due to a lack

of knowledge or self-management of the disorder. So the following PICO question was

formulated to try and determine the best evidence to reverse this cycle. In patients newly

diagnosed with CHF, how does teaching self-management strategies and recalling them with the

teach-back method prior to discharge compare to standard teaching before discharge affect

readmission rates and overall knowledge? The purpose of this PICO question and the overall

project is to try and decrease hospital readmissions of people with CHF and improve their overall

health and quality of life by teaching them how to better take care of themselves. Teaching

people self-management strategies before discharge can help them learn signs and symptoms to

look for, including weight gain, shortness of breath, or increased edema, which could mean a

deterioration of their CHF. Self-management strategies can also teach them how to manage their

medications properly, stay on a strict low sodium diet, and have exercise regimens recommended

fitting their lifestyle. All of this brought together by a new method of teaching will hopefully

decrease exacerbations of heart failure and overall decrease readmissions.

A person who is hospitalized once for the diagnosis of heart failure has a 27 percent

chance of readmission within 30 days of discharge; therefore, the need for something to change

is imminent and self-care strategies with teach-back can be the answer. Self-management

strategies learned through teach-back can have an overall goal of improving self-management

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and decreasing readmission rates into the hospital after discharge. Studies show that increased

participation in one’s own care can decrease a person’s chance of being readmitted into a

hospital substantially. As stated by Horwitz and Krumholz (2011), “…improved self-

management skills may reduce the odds of readmission at one year by 40 percent” (p. 5). Thus,

improper self-management, including not taking medications at the appropriate times nor eating

the correct diet, can lead to a one in five hospital readmission being from heart failure. Not only

will this help put a new strategy into practice, but it can also identify weaknesses in how people

are being taught and discharged in hospitals today.

With self-management in mind the best population for this project will be anyone who is

admitted into the hospital for the first time under the diagnosis of heart failure and be of the age

18 or older. The patient may be on a variety of medications such as diuretics, beta-blockers, or

angiotensin-converting enzyme (ACE) inhibitor. This population is more prone to having

complications with their management of CHF, due to it being new, and would benefit the most

from an interventional standpoint.

Framework

To help develop and implement a new strategy for improving the health and quality of

life for CHF patients, an evidence based practice (EBP) framework has to be chosen that best

suits the needs of patients with this clinical diagnosis and answers any questions regarding this

condition. The most practical and clinical scenario focused EBP model for this scenario is the

IOWA model. The IOWA model is more clinical based and driven on results received. The

Iowa model also helps show how to develop, introduce, and analyze evidence-based practice in a

clinical setting (Doody & Doody, 2011). It incorporates the entire healthcare system from the

patients to nurses, as well as from the physicians to the methods they choose in their practice

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(Melnyk & Finout-Overholt, 2011). There are many steps to this model and it all begins with a

clinical problem in need of a change. In this project the problem in need of a change is the way

people are educated on their disorder and how to take care of themselves. Also, once the

teaching is done there needs to be a way to confirm if the patient actually retained anything that

was taught to them. Once the problem is identified and deemed an importance to a facility, then

the next step is searching through current literature on the topic. By analyzing literature on the

need of patient’s understanding of medical conditions, the demand for change from current

medical practices is justified.

If the research reveals enough evidence to make a change, then a new plan to improve

outcomes should be developed and implemented. The new plan would be focused on strategies

for decreasing hospital readmissions and improving self-care skills in order to increase the

quality of health, as well as the patient’s quality of life. Once the outcomes are pinpointed, then

baseline data for the change is gathered. The baseline data that is gathered will be focused on

asking patients questions to assess their current level of knowledge on what CHF is, the

understanding of signs and symptoms that derive from the condition worsening and symptoms of

the condition worsening, as well as the understanding of the medications needed to help

overcome the illness. All of this information will then be used to make a new guideline for

teaching people different self-management strategies and evaluate the level of knowledge in

patients to help ensure that the proper level of understanding and knowledge is obtained.

By formulating a new guideline, the new approach can become a tactic that is

implemented in pilot studies in various hospitals. For example, the focus of this project will be

on a cardiology floor in a nearby hospital that admits numerous CHF exacerbations a week. The

results that the guideline yields will be taken into perspective and modifications to the guideline

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will be made. Results that will be looked for are any increase in knowledge of the disorder,

medications, diet, and signs and symptoms or any lack thereof. Long term results that will be

monitored are readmissions into hospitals for any reason pertaining to poor health. Once the

guideline is set, the results and data will be weighed to see if the change is appropriate for

implementation into practice at the hospital. Another theory that can further assist in guiding this

project is Dorothea Orem’s “Self-Care Theory”, which will show how quality of life is important

and what needs to be done to keep it up.

The self-care theory designed by Dorothea Orem describes how everyone has activities

that he or she can perform on their own in order to keep up their well-being and quality of life

(Orem, 1991). The theory also talks about how one should have a good balance between rest and

activity and sustain human functioning by preventing harm to the human body (Orem, 1991). If

a person has a condition or illness, proper self-care should include proper administration of

medicines, reorganizing self-care in dealing with the disorder, and being conscientious of

symptoms that can develop from the condition. This self-care is ultimately the responsibility of

the individual with the disorder.

The self-care theory’s utility in framing the project is the strategy of proper self-

management. This theory resembles the EBP model in which it relates to the overall objective of

increasing individual's self-management in dealing with certain disorders by reinstating the need

for patients to be active in the recovery process that is crucial to his or her survival. Without

proper self-management skills in a person’s life, patients will not know what to look for in CHF

exacerbations and will be decreasing their overall well-being. This theory and EBP model helps

give this project the proper framework by outlining how to implement the project and justify

how important self-care is to a person’s quality of life. After the framework of this project has

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been made clear, evidence will then be researched to reinforce the significance of this project.

The Iowa Model and Self-Care Theory help guide this project by collecting pertinent

information through evidence-based practices. The information gathered is regarding a person’s

self-care skills and what they can do to decrease their chance of readmission. The Iowa Model

will help gather and organize material found on self-care activities and deficits, and research new

possible ways of teaching people what to do. One way of decreasing readmissions and

increasing self-care is the use of a teach-back method. This method will help increase the

knowledge of patients in order to help them take care of themselves while outside the hospital.

Once a strategy is found, such as the teach-back method, the Iowa Model will help instill it into a

clinical setting. The model will test for change and see if the new way of teaching is actually

beneficial in keeping people with CHF out of the hospital. If it proves to be beneficial, then

further adaptation into a clinical setting will occur. The self-care theory will help guide this

project through its emphasis that people should be self-reliant and perform activities on their own

in order to maintain their life. The theory also mentions that people are distinct individuals;

therefore, creating a teach-back method will help each person learn this material in their own

way. Allowing a person to communicate back to their instructor in their own words will help

them grasp the information more clearly and improve their overall outcomes.

Review of Evidence

Researching evidence is a very time consuming task and can lead a person down many

roads of non-applicable evidence. However, when research is performed properly, the amount of

evidence that is found can be astronomical and overwhelming to a topic that is being researched.

This is when different search strategies are used to decipher the evidence and use different key

terms to cut through the bulk of the evidence. This will allow more time to focus on the more

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important and topic-oriented evidence. For this project, key words that were used to help narrow

the search were “congestive heart failure”, “heart failure”, “self-management”, “teach-back”,

“medication compliance”, “health literacy”, and “discharge teaching”. In some instances these

words were grouped together in different ways to try and find more relevant information on the

topic at hand.

Management Through Increased Health Literacy

The search turned up different kinds of material but in almost every instance the evidence

pointed to improved self-management strategies and information recollection resulting in a

decrease in heart failure exacerbations and hospital readmission. Morrow and others (2006)

conducted a correlational study that dealt with the health literacy of the older adult including

cognitive ability, education, and health variables. The sample size of this study was 314

conveniently chosen participants with CHF and taking at least one medication pertaining to their

CHF. The participants in this study were measured by a questionnaire called the “Short Test of

Functional Health Literacy in Adults (STOFHLA)” and sensory tests (Morrow et al. 2006, p.

669). Some findings presented in this article were that cognitive tests were lower in African

Americans, males, individuals ranging in the age of 60 or older, and the less educated. Health

literacy is drastically affected with age, education, and cognitive ability. According to this

article, the lower the cognitive ability of the patient then the less likely the patient was able to

recall health related information. A lower cognitive ability will overall decrease the likelihood

of understanding information relayed to them about their disorder and decrease their chances of

self-management. A potential resolution for the inability to recollect health information could be

to lower the level at which the information is taught and explain it on a more basic level. A

general level for literature pertaining to health information is the fifth or sixth grade level so

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everyone can comprehend it.

To continue on with health literacy, Wilson, Baker, Nordstrom, and Legwand (2008)

compiled evidence for an experimental study on teaching people about health information and

how the teach-back method was applied to the information that was taught. This method of

teaching people was used on mothers and their knowledge of childhood immunizations. The

sample of mothers included in the study was mostly African American and single mothers with

an income of $20,000 or less. In the study the nurses gave pamphlets on the poliovirus vaccine

and the pneumococcal vaccine, which allowed the nurses to proceed with verbal instructions on

both. After each mother was taught the information they were then asked questions pertaining to

risk factors, benefits, and safety of each vaccine. If they answered the question correctly, they

would receive full credit; however, if they answered questions partially or incorrectly, they

would receive fewer points. These points were then totaled up and put in a table to show how

the teach-back method worked among people’s aptitude towards health literacy. The study

showed that more correct answers were given for the poliovirus vaccine in general as compared

to the pneumococcal vaccine that had more partial or incorrect answers. The sample size of this

study was small and potentially affected the outcomes of this study. However, the study shows

that the teach-back method is a possible strategy to improving comprehension of health related

information and possibly needs to be tested further. Although this article does not pertain to

heart failure and produces different results, the research does highlight the importance of the

teach-back method, as well as how the method should be used to address educational issues.

In an article by Smeulders and others (2010), researchers obtained information on how a

self-maintenance program increased the quality of life in people with congestive heart failure.

The study had a sample size of 317 patients with CHF. One hundred and thirty one of the

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patients were randomized as a control group with usual care while 186 were in usual care in

addition to the self-management program. This study was done to teach participants medical,

emotional, and social self-management skills over a 21-class period. Some skills included goal

setting and action planning. The outcomes that were measured were symptom management,

self-care behavior, and quality of life. Major findings in the study were improvement in

symptom management skills that led to an overall betterment or increase in physical activity.

With the increase in activity came an increase in quality of life, which is the main purpose of

self-management.

Management Through Improved Self-Care Strategies

A study by Armbrister (2008) for nurse practitioners examines how self-management

improves outcomes in patients with chronic conditions and states things that can be managed by

the patient. The article also talks about how regular patient education, such as current discharge

teaching, only focuses on a patient’s usual treatment and education teaching. This is opposed to

interaction between the provider and patient with an individualized plan as in self-management

education. This method allows for patients to become an active participant in their health care in

order to obtain understanding and a sense of control regarding their medical condition.

As stated by Armbrister (2008): …seven skills have shown to improve patient outcomes:

(1) review of medication purpose and adverse reactions, (2) adherence to a low-sodium

diet, (3) measuring daily weights, (4) diuretic self-adjustment, (5) identifying and

monitoring for congestive symptoms, (6) smoking cessation and limiting alcohol, and (7)

physical activity. (p. 25)

For each skill outlined by Armbrister, the underlying framework focused on three stages

of self-management strategies. They include a managing stage, problem solving stage, and a

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confidence building stage. In the managing stage information is provided so the patient can

identify foods with high sodium as in the diet portion or signs of congestive symptoms such as

fluid overload. With the problem solving stage, a patient is given knowledge to try and correct

any problems or stay clear of something that may cause an issue. An example of this would be

removing any salt from the kitchen when on a low sodium diet or adjusting medications with

signs of fluid overload. The confidence building stage is to try to promote healthy living and set

goals so a patient can reach them and obtain a higher quality of life. Examples of confidence

building would be setting a goal of walking every other day for 30 minutes and continuing to

strive for walking a longer distance for an additional amount of time each day or week.

Self-management of medications, daily weights, exercise, and diet can be very difficult

for the elderly population due to the lack of noncompliance. Krumholz, Amatruda, Smith,

Mattera, Roumanis, Radford, Crombie, and Vaccarino (2002) conducted a randomized control

study to see what could be done to decrease the hospital readmission and mortality rate in people

aged 50 or older. The study included 88 participants, 44 randomly selected to the intervention

group and 44 with usual care. They also had inclusion criteria of having CHF as a previous

admission diagnosis or chest X-ray. Some exclusion criteria for the study were that patients

could not be transferred from another hospital, nursing home, or have a terminal illness along

with CHF. After the participants were chosen and discharged from the hospital they were asked

to return within two weeks to be educated on what they would need to take care of themselves

while at home.

In the education phase a cardiac nurse reviewed what the patients had already known so

they could explain any areas of concern that individuals were not clear on. After that they were

just continually educated and questioned so they would optimize their compliance with the

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?? difficulty maintaining compliance or just due to noncompliance


disorder. After they were educated and sent back home the participants were then contacted by

phone at different intervals throughout one year period just to follow up and reinforce

information taught. The calls were not made to change habits that were being made, but to just

check-in on the patients and see how they were using the teaching. If a severe problem was

noticed then the nurse would intervene. Outcomes measured by the study were hospital

readmission rates for CHF and any other admission reasons and death rates. Major findings that

were derived from the study were a reduction of 39% for readmissions for any medical reason

and a reduction of 47% for readmissions for CHF or cardiovascular disease. Cost of care was

also decreased by $6,985 per patient in the intervention group (Krumholz et al. 2002). The study

implies that education and support intervention without any kind of medical intervention is

effective in reducing hospital readmission rates.

If self-management cannot be obtained then a self-care deficit will occur and decrease the

quality of one’s life. Based on the work of Britz and Dunn (2010) on self-care deficit, they show

how a self-care deficit can lead to a decreased quality in life for people who were recently

hospitalized for heart failure. The study included thirty people who had been recently admitted

to a hospital with a diagnosis of heart failure and had them answer a questionnaire. Outcomes

measured relationships between demographic variables, self-care maintenance, self-care

management, self-care confidence, physical quality of life, and emotional quality of life. Some

major findings were that female patients had higher scores on their questionnaires and older

patients had a higher quality of life than younger patients. Also, Britz’s study explained a direct

correlation between self-care abilities and one’s quality of life. Self-management strategies were

shown in this article including people using a pill counter, checking lower extremity swelling,

and daily weights. If the patients were to implement these strategies and have confidence in

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doing them, then there is a direct correlation with improvement in total physical and emotional

quality of life.

Another method for researching literature for this project was to look at clinical practice

guidelines pertaining to heart failure. The guideline by Institute for Clinical Systems

Improvement (ICSI) (2009) that was done on heart failure has objectives of decreasing

readmission rates, better managing medications, diagnosing and treating heart failure patients

properly, and improving overall care by providing adequate in-depth education. The target

population is any person with diagnosed heart failure, age 18 and older, and has been

hospitalized due to it. Outcomes that were measured were hospital readmission rates, change in

quality of life, compliance and proper use of medications, and disease progression. The

guideline is intended for use by most healthcare workers including nurses, physicians, and nurse

practitioners. The guideline optimizes help in diagnosis, management, risk assessment, and

treatment of this type of patient.

The guideline by ICSI (2009) included studies with different levels of evidence and

found through searches of different databases to collect an appropriate amount of research

articles. Types of studies found included randomized control trials, cohort studies, non-

randomized trials, case-control studies, and cross-sectional studies. There were different types of

synthesized collective articles that were reviewed in the guideline including meta-analysis

research articles and systematic review articles. Once all of the research articles were collected,

a team was formed to produce recommendations for the guideline. This team consisted of six to

twelve members that included physicians, nurses, and other relevant healthcare workers related

to heart failure. After the team finished their recommendations, the guideline was reviewed and

approved by a third party outside the research team.

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Recommendations that were based off the team’s research included evaluation of heart

failure, treatment of the different kinds of heart failure, pharmacological management, non-

pharmacological management and emergent management of heart failure. Some

recommendations include monitoring daily weights as to detect an early sign of fluid retention,

treat all heart failure patients with a beta-blocker unless contraindicated, and testing brain

natriuretic peptide (BNP) can help in detection of heart failure (ICSI, 2009). The

recommendations can lead to a better approach for appropriate management, improved overall

care, and decreased hospital readmissions. To implement this guideline, patient self-

management strategies need to be stressed. This could be done through self-management

education and other ways to keep the patient engaged in their own care. The guideline gives

several critical areas of education. They are diet, daily weights, exercise, medications, follow-up

care and the importance of it, and things to do if symptoms get worse. The guideline implies that

self-management is a significant strategy to improving and maintaining the chronic condition of

heart failure.

With all of these articles pointing to a clear problem in patient comprehension through

poor teaching strategy, there has to be a different way to administer discharge teaching. The way

that will be reviewed and tested in this project is the teach-back method. In a similar

interventional study by Roeman (n.d.), people that were admitted into the hospital under the

diagnosis of heart failure had the teach-back method applied to them before discharge home.

Before the patient was sent home, they were given their discharge instructions and reassessed

through teach-back. There were 259 people invited, 100 people enrolled and 159 people not

enrolled. After teaching was completed and the patient was sent home, they were followed up

with 4-6 weeks later. Since discharge, 5% of the enrolled group had been rehospitalized for a

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Would stress importance of education that fosters improved self care than focus on poor teaching


HF exacerbation while 11% in the non-enrolled group had been rehospitalized. There were also

two sets of scores recorded to evaluate the teach-back process. The initial score was 62% while

the final score was 99%. This implies that the teach-back method could possibly be a good way

to implement discharge teaching.

Good – need to summarize before moving on

Evidence Appraisal

In the first RCT by Smeulders et al (2010) the level of evidence was a II for it involved a

randomized control trial with its participants allowing the article to be a quality research article.

Other strengths that this article included were a large sample size for longitudinal follow-up and

although the study was short, it provided short-term results showing the affect of the study. One

noted weakness portrayed in the study was the place it was conducted, which was only in the

Netherlands. Participants were asked for self-reports at the conclusion of the study instead of

assessing physical fitness, which can make the study skewed since results are received from

subjective data. Another weakness is that there were no long-term results shown since the study

was short. The information in this article was average since it implies that self-management

programs can improve short-term self-care, but does not improve any self-care past six months.

The quality of this article was fair since it had proper evidence to show outcomes, but it could

not be put into practice.

The other RCT by Krumholz et al (2002) is a level II also because it used random

controlled trials for its selection of participants. Some strengths in this article were the length of

the study, inclusion and exclusion criteria, level of evidence, and it shows a positive result.

Weaknesses included the small size of 88 participants and that the study was done only at one

hospital. The quality of evidence was obtained from a properly designed RCT. There was an

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Assignment; selection is convenience


abundant amount of evidence showing the comparisons between the control group and the

intervention group, with that analyzed evidence positive recommendations were given. This

evidence shows that education and support when managing CHF improves overall outcomes.

Statistically, education and support reduces hospital readmissions and potential death. The

quality of this article was good because it had consistent results and well conducted studies.

In a descriptive article by Wilson et al (2008) that is a level IV implies valid strengths

and weaknesses. Some weaknesses are the low level of evidence, a small sample size, only one

clinic observed for the study, the level of literacy in the women were low and there were not any

of a higher level. Strengths included the study being a valid source for determining how literacy

plays a role in comprehension of material involving health information, and data were compiled

into tables to show quantity and quality of evidence. The evidence throughout the article

showed that a low level of literacy has a major affect on comprehension of health material. The

quality of the article was fair due to the limited number of participants and inability to adapt the

strategy into practice; therefore, the information was not of great strength.

In the article by Morrow et al (2006) the level of evidence is a V with the quality being

fair. The weaknesses in the article were the study being generated from only one hospital, nearly

half of the participants were African American, the tool in the study could underestimate cultural

contributions, and it only provided a low level of evidence. Strengths include being a valid

source for determining health literacy in a patient and the sample size was fairly large. The

evidence was consistent with how health literacy is drastically affected with age, education, and

cognitive ability. The descriptive article by Britz et al (2010) is a level IV for evidence, but the

quality of the evidence was good. Some weaknesses noted in the article were small sample size,

same type of participants causing homogeneity, and the evidence was subjective. The strengths

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Most would call this V


in the article were strong inclusion and exclusion criteria for picking participants and even

though the sample size was small it produced meaningful results.

In an opinion article by Armbrister (2008) the level of evidence was very low since there

was no real evidence but the quality of information is fair. Some weaknesses in this article were

that it was a level VII evidence and primarily opinion by experience. There were no real

strengths due to the fact of this study producing low level evidence. Any recommendations that

come out of this article will be of lower quality due to the inadequate evidence produced to prove

it. However, it does give rise to possible thoughts that can be taken into account for improving

overall outcome in people with CHF.

The guideline that was researched by ICSI had a strong level of evidence since it was a

meta-analysis of other studies. Strengths included using randomized control trials, cohort

studies, cross-sectional studies, and nonrandomized control trials. Recommendations that were

depicted from this guideline showed a possibility for vast improvement in readmission rates,

medication management, improving overall care. The recommendations that were given in this

guideline can be taken into serious consideration since it was of good quality and showed

positive results in CHF management. All of the recommendations given could be put into

practice and are intended to do so by nurses, nurse practitioners, and physicians.

In the interventional pilot study by Roeman (n.d.), there were some visible weaknesses

with it being a low level of evidence primarily since it is a pilot study. On the other hand, its

strengths were that of a big sample size and physical testing was used in order to collect the data.

Recommendations that were received from this study were that the teach-back method could

help drastically lower readmission rates and increase knowledge pertaining to CHF. The

recommendations can be taken into consideration for potential use of the teach-back method but

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are not of great quality since it is from a study with low level of evidence.

The evidence supporting these articles were of good quality, showed improvement in

quality of life, and showed how better self-management can lead to decreased readmission rates;

therefore, the grade given for the overall recommendations was a B. Recommendations that

were depicted from these articles varied in quality depending on the strength of the article and

how in-depth the evidence was in each. One recommendation from the article by Krumholz et

al, is that education and support when managing CHF improves overall outcomes. Another

recommendation perceived by Wilson et al, was that using a teach-back method can improve

understanding of health related information. In the article from Morrow et al, recommendations

included formulating interventions for low health literacy in order to improve health outcomes.

Some interventions could include training in simple cognitive skills. Other recommendations

included assessing self-care confidence and knowledge deficits prior to discharge and

recommending self-management strategies through teaching to improve overall outcomes. All of

these recommendations are beneficial towards this project since they show benefits in increasing

one’s knowledge to improve overall health. They also show that a teach-back method can be

crucial to improving a person’s grasp on information and self-management strategies.

In the search for the literature that was previously discussed all different levels of

evidence were found and reviewed. The articles ranged anywhere from level II to level V in

evidence, but they all supported the use of self-management strategies or teach-back to improve

outcomes in congestive heart failure patients and decrease hospital readmissions. As stated in

the research grid there are two randomized control trials (RCT), three descriptive research

articles, and one opinion article that were used to collect evidence. They all varied in strengths

and weaknesses with information that was provided but they all brought about evidence

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supporting the PICO question. The recommendations were well thought out and geared towards

the project but some were poorly developed with the evidence that supported it. See Appendix A

for further information on the evidence grid.

Heart failure is the leading cause of death versus any other disorder in the United States;

therefore, something needs to be changed in order to reverse this trend and make people with

heart failure live a higher quality of life. The PICO question deals with decreasing readmission

rates through better education of self-management and better strategies of learning the material,

such as the teach-back method, and seeing if this will have better outcomes than teaching that is

in place today. This is where literature reviewed makes a big impact because studies that have

been performed can be reviewed and a new project can be formed to improve the overall health

of patient with heart failure. After looking at all of the evidence, a project that can be ascertained

would be to increase education and knowledge about the disorder and self-management

strategies. This information could then be reiterated to the educator, using the teach-back

method, to see if an improvement has been made. These strategies have been evaluated and

recommendations have been provided to see if this method would actually make a difference.

The overall objectives of various trials produce results that validate how self-management

strategies, better teaching before discharge, and increasing overall knowledge truly have a

positive impact in healthy outcomes for patients with CHF.

Needs Assessment

Heart failure is the most prominent cause of death in the United States today, and an

intervention that can try to change that is the inpatient discharge teaching strategy. This is where

a potential problem can be found in the healthcare system. To be more exact, one problem could

be occurring at the teaching level once a person is diagnosed with heart failure. This conclusion

21


Not clear


Not as well supported


has led to a more in-depth analysis of a local hospital in Montgomery, Alabama. In

implementing EBP one should first review the methods and outcomes of the current facility. For

this project, how people are taught about their new CHF diagnosis and concerns in patient and

staff outcomes were reviewed.

First, the program that is currently in use involves case managers, care advisors, nurses,

and nurse managers. When a patient is admitted under the diagnosis of heart failure, he will be

flagged so a case manager that deals with heart failure can talk to him. Once the case manager is

notified, she goes and talks to the patient about their new diagnosis. This discussion involves a

packet of information dealing with foods to eat, exercises that should be done, and signs and

symptoms to be aware of. Also in the packet is a heart failure zone sheet. This tries to involve

the patient with his care and look for possible signs of worsening heart failure. If he feels he

does not have any of the symptoms listed, then he is in the green zone. If some symptoms are

noticed, he is in the yellow zone and should contact his doctor’s office. If the symptoms

progressively get worse to where it is crippling him, he is in the red zone and should go the

emergency room. The case manger talks about each piece of information in the packet and

explains how important it is to adhere to what is being taught.

After this information is discussed with the patient, the case manager asks if he would

like to join the hospital’s heart failure program. If he agrees to the program, he will be followed

up with after discharge and will have records kept on him. The follow up would consist of a

nurse calling the patient’s home and asking how he is feeling and if he has any questions about

his new medications or diet. The nurse would also ask for his daily weights and if he is

experiencing any swelling in his ankles or feet. Depending on how debilitating the heart failure

is, the more frequently the patient could be called after discharge. The normal follow up

22


Could start here


timeframe is one week after discharge and one phone call a week for 2-3 months. If the person

declines acceptance into the program, he is left with the teaching and no follow-up.

There are many people that are involved with the readmissions of people that have just

been discharged. This list spans from the case mangers that have interaction with the patients up

to the CEO of the hospital dealing with reimbursement from health insurances and Medicare.

The key stakeholders in this equation are the case managers on the cardiac care floors, the care

advisor dealing with the current heart failure program, the CEO, the CFO, and the CNO. Every

day a census is printed by the care advisor and sent to the case managers to look over for any

readmissions dealing with heart failure. The case managers then search through the census, and

if they find a readmission from heart failure, they flag it and come back to it.

Once they come back to the patient, they look at current labs, such as a proBNP and chest

x-ray, to see if this admission is heart failure related. If it is heart failure related, they search the

heart failure program to see if they are in it. If the patient is in the program, they find the reason

to why they were readmitted. In some instances, as stated by a case manager, it may be due to a

needed medication that was not prescribed. In most other instances it was reported that the

teaching had not been adequately understood and retained. One instance that reflects the

teaching is the patient’s inability to know what symptoms to look for and why it could be

happening. This is known since the patient was asked why the physician was not called earlier

after experiencing signs of weakness. Once this information is found out, it is passed up the

chain to the care advisor of the program and onto the CEO. The information that is received by

the stakeholders leads to a reaction of what can be done to improve these indictors and decrease

these readmissions.

23


Indicators for improvement are readmission rates for heart failure patients and the amount

of people that deny acceptance into the program. This program was started in 2009, and since

then over 600 people have been asked to join the program, and only roughly 230 patients are

currently in it. This is only a 38% acceptance rate into the program. If this number continues to

stay low and stagnant, the program will not have success when dealing with readmission rates.

Also the average readmission rate in Alabama is 15%, and the current facility is right around the

average range with 15-16% readmission rate from heart failure (Mitchell, 2011). This

readmission rate may be improved if a new evidence based teaching style is employed. One way

to try and improve it is with the use of the teach-back method. This will hopefully help patients

retain information, decrease readmissions, and satisfy stakeholders.

Implementation Plans

The evidence gathered above supports that an intervention can be effective in updating

teaching strategies for patients with heart failure. If teaching is not done properly the first time,

quality of life can be affected. A possible intervention to be implemented into the current facility

would be the teach-back method. The teach-back method will be incorporated in place of the

regular discharge teaching for patients with congestive heart failure. This new method of

teaching will be applied to any person admitted under the diagnosis of heart failure, 18 years and

older, and not have any cognitive deficits. The evidence supports this choice since most

readmission reasons for heart failure patients are due to exacerbations stemming from a lack of

knowledge about things to look for when their heart failure is worsening. If patients had a better

understanding of what to look for, then they could get in touch with the doctor before it gets out

of control.

The major aspect that the teach-back method brings to the hospital is the method in which

24


the difficult information is taught and comprehended. With this method a teacher can portray

information that is important and in return have them reiterate it back to them to understand if

they grasp it. The best way to know if the patient is learning is to tell him to repeat the

information as if he were teaching his friend or spouse. If he cannot repeat a clear and

understandable topic pertaining to heart failure, then the teacher knows more teaching is advised.

If this continuously happens, then maybe a different approach to the topic is warranted. Also

with this method, the repeating of the material will help the patients absorb the material because

they have to talk about it. When the information is repeated back, it allows for quick

measurement of a patients learning outcome.

The teach-back method also opens up the teaching to open-ended questions and not just

yes or no questions. An example of the teach-back method is teaching a patient about some signs

and symptoms to look for in worsening heart failure. One would be swelling in the feet to where

shoes are tighter than normal and uncomfortable to wear. The teaching would advise to call the

physician and ask for further instructions. If the teaching were to work correctly, the teacher

would ask how the patient could tell his spouse about worsening heart failure signs. The patient

would then reply, “If I were to observe abnormal swelling in my feet to where my shoes do not

fit properly, then it is advisable to call my physician.” Another response for the topic of the right

diet would be, “Increased salt intake can increase the work my heart has to do from increased

water retention.” These would be an appropriate teach-back to the teacher, illustrating the

patient understands what was taught to him. Not only does this help them to retain the

information but it also helps them remember why they should or shouldn’t be doing something.

The implementation process will be concise and to the point as to try and avoid any

potential barriers that may present themselves throughout this process. The first step in

25


implementing this project into the hospital is forming a team. The team will consist of nurses,

dieticians, nurse managers, and case managers. The nurses will be the primary teachers during

the patient’s stay in the hospital. The dietician’s will help in reinforcing the diet modifications

that are supposed to be adhered to after discharge. The nurse managers and case managers are

the ones that will bring about the change to the different floors and units throughout the hospital.

They will install this new method of teaching by illustrating it to their nurses and teaching them

what they need to be doing and looking for while educating their patients. This team is the

foundation for making this implementation work hospital wide.

Once the foundation is built, then the nurses can begin using this new teaching strategy.

The teaching will consist of an educational binder consisting of information that is taught by the

nurse to the patient during his stay. Also included in the binder will be a self-efficacy

questionnaire (SE) that will be done before the teaching and after discharge to monitor a change

in knowledge. The information in the packet will include education on medications, diet,

exercise, signs and symptoms pertaining to CHF exacerbations, and daily weight monitoring. It

will cover new medications that the patient is being put on, what kind of diet he should adhere to

and what to avoid, and how much he should exercise throughout the week. Teaching will be

done on signs and symptoms that need to be looked for in worsening heart failure and when to

notify someone. An example to monitor for worsening heart failure is daily weight monitoring.

This is one the easiest but most important new life rituals for these patients since any gain over 3

pounds in 1 to 2 days will notify the patient to call the physician. Each patient will be given a

calendar in order to assist with keeping track of weights.

Documenting change in the patient’s knowledge base from the intervention will be

primarily based on the teacher’s review. This means that during the teach-back if the teacher

26


does not feel the information was correctly reiterated, significant change has not been made.

Further teaching will be advised, and weak spots will be focused on. Also the questionnaire

mentioned earlier will be a step to documenting change. Again if the answers aren’t felt

appropriate to the amount of teaching that has been conducted, then more teaching will is

warranted. Once the teacher feels confident that the patient has a good handle on the

information, a box will be checked off saying that section of information has been completed.

This will be used to continuously check and see what still needs to be taught and what has been

taught during the course of the hospital visit. However, all teaching should be done in one

sitting, but in the realistic world this leaves “the door open” for things that can come up and draw

the nurse away from what they are doing.

During the implementation process possible barriers can hinder the success of this

intervention. Barriers can range from implementers in the intervention to patients willingness to

learn. A potential barrier can be the unwillingness of the nurse to take time and implement this

new strategy due to disbelief that this method is more effective. Instead they could just continue

teaching the way they have been or not fully commit to how the new strategy is suppose to be

done. The nurse might just teach the material and only ask for a little teach-back or may not

reevaluate what was reiterated and just move on. Another possible barrier can be the lack of

knowledge by the nurse on heart failure information. The nurse plays the most influential role in

how this new method will be taken in and used in the hospital. If there is not compliance with

them, then the intervention will fail. Another potential barrier could be the unwillingness of the

patient to learn this new material. If they are unwilling to learn, then it does not matter how well

the nurse presents the material.

With all of the possible barriers listed above, well thought-out strategies need to be

27


developed as to how to overcome them and succeed in this intervention. In order to help the

nurses, meetings will need to be held with them to show appreciation for willingness to accept

this new intervention. They will also need to be asked if they have any questions regarding

teaching about heart failure. This can be a good time to instruct them on what is to be taught and

how to do it. Also, other resources including clinical educators can be available to help with

education and provide examples of what to teach for the nurse. This will allow everyone to be

teaching the same information in the same way and not get mixed results. Talking to the nurses

in small groups can also make them feel more important and make them feel like they are

making a change for the greater good. Ways to decrease resistance from the patient is to talk to

them about the possible rewards this knowledge will bring. Rewards include a better quality of

life through less time spent in the hospital and more time being active with family members.

In order to get the teach-back method implemented into the hospital, resources and

financial needs should be discussed. Even though they play a role in the implementation

process, the need for resources and finances are minimal. Resources will include the team that

was formed earlier to bear the workload of teaching patients and getting in touch with patients

after discharge. Financial concerns for implementing the teach-back method include money

spent on the binders, questionnaires, calendars, and using phones to communicate with patients

after discharge. The other concern will be the time spent teaching each patient but this cannot be

fully grasped until the small test of change is conducted. The resources and financial concerns

will be the same for the small test of change but completely absorbed by the graduate student for

this project. So in the small test of change the student will do all the teaching and evaluating of

the patients and printing of questionnaires.

Before the teach-back can be implemented fully as a system change, it needs to be done

28


on a smaller scale to see how well it is adhered to and if change is imminent. The small test of

change that will occur in February 2012 will include ten to twenty patients admitted under the

diagnosis of heart failure for the first time. The inclusion criteria will include that this is their

first admission for heart failure, be over the age of 18, and be admitted to the second floor in the

hospital. Some exclusion’s include cognitive impairment, life expectancy of less than three

months, unable to have the ability to communicate on a phone, and heart failure due to the use of

illegal drugs. When patients have been selected, they will be recruited through information

letters that will be handed out by the researcher and nursing staff. The letter will contain the

details that will be happening in the project and include benefits that they might inherit by

participating. If they agree to participate, a consent form will be filled out and signed regarding

the risks and benefits that might happen from their participation.

Once the consent form is signed, the patient will be given a questionnaire to be filled out

to check their level of knowledge on the new diagnosis. After that is completed, teaching will

begin, and the teach-back method will be applied as mentioned earlier. After the teaching is

done, the teacher will reassess the patient’s knowledge level and possibly reiterate some of the

weak points. This will help ensure that the patient fully understands the material that is being

taught and the significance of it. Following discharge the patient will be followed up with and

asked questions from the SE questionnaire and the Minnesota Living with Heart Failure

Questionnaire (MLHFQ) over phone conversation. This will be done to further evaluate the

teaching that was done in the hospital for knowledge retention and to see if their quality has been

affected by their new diagnosis. The component that will be implemented in the small test of

change will be the teaching of the patients using the teach-back method and answering of

questionnaires for data purposes.

29


You ultimately did not use a consent form right -


The stakeholders that are involved have a real positive response to the results that I hope

receive. The main stakeholders that I will have a chance to show are the nurse manager and case

manager for the cardiac floor that the project is going to be implemented on. They are very

receptive in the sense that it looks to have good outcomes and could be possibly implemented

into a hospital wide discharge teaching strategy. They do not however think that it is something

that could be implemented in this facility since their current practice has good outcomes.

Evaluation Plans

Once the teach-back method has been fully implemented into the hospital, it will need to

be evaluated to see if improvements in outcomes are occurring. The entire purpose of this

implementation was to find a way to decrease readmission rates for patients with heart failure by

increasing their knowledge base and trying to get more patients into the heart failure program. In

order to evaluate the purpose of the project two questionnaires will be given and interpreted.

The two questionnaires will be the MLHFQ and a CHF SE questionnaire. The MLHFQ is a

quality of life questionnaire that will evaluate if a person’s quality of life (QOL) has been

modified from the teaching that they have received. The SE questionnaire will determine if the

patient is retaining any of the information that was taught and how they are applying it. Both of

these questionnaires will measure the goals of increased knowledge in self-monitoring and

increased QOL. You can see the questions on these tools as shown in appendix C.

The two questionnaires will be done at different intervals in the patient’s transition into

living with heart failure. This means that the SE questionnaires will be monitored both in and

out of the hospital, and the MLHFQ will be monitored solely outside the hospital. The SE

questionnaires will be monitored to show an improvement in knowledge from when the patient

was admitted to a couple of weeks after discharge. This is one of the most important things to

30


At national average – seems improvement is an option!!


Not clear – has justification supporting good outcomes?


decreasing chances of readmission. If each of these patients improves their knowledge on heart

failure, their chance of readmission drops drastically. The SE questionnaire will be evaluated on

a grading system. There will be different types of questions with answers ranging from not

being capable of doing or knowing something to being extremely capable of doing or knowing

something. Scores will range from zero to four with four being the most confident. The

purpose of this questionnaire is to receive high scores after discharge. The higher the score, the

more confident the patient is in taking care of oneself and less likely to be readmitted.

Once discharged the patient will receive a follow up phone call to ask them questions

from the MLHFQ and the SE questionnaire. The MLHFQ will also be graded like the self-

efficacy questionnaire, but the lower the score the better. Questions will pertain to symptoms

that are common in worsening heart failure, how well they perform their daily activities, and

their overall wellbeing including attitude. If these symptoms aren’t present or they haven’t been

depressed when asked, then the heart failure seems to be well controlled. Scores on this

questionnaire will range from zero to five with five meaning that heart failure has prevented a

higher quality of life. These questions will help show if their quality of life has improved or

declined since being in the hospital. If the patient shows signs of an improved quality of life, the

teach-back method could be shown as an improvement in ways to teach health related

information. The phone call is also a great time to ask if they have any questions that have

come up since they last talked to their physician. After the first phone call, weekly phone calls

will be made to check in on patients and ask about their daily weights and medication

compliance. This will help keep track of patient progress and see if complications are imminent

which could possibly lead to readmission.

Other outcomes that will be monitored are readmission rates for patients with heart

31


failure. Over the next 6 months to 1 year, readmission rates will be monitored to see if the teach-

back method has made any improvements. This would have to be monitored for every patient

coming in with the diagnosis of heart failure by being screened for previous admissions.

Monitoring for these patients will be done daily by checking the census that is given to the case

managers. If the recently discharged patient was readmitted under a different diagnosis, that

would not count against the recently implemented intervention.

Monitoring these outcomes can prove beneficial for the hospital in multiple ways. If the

outcomes show an increase in knowledge and decrease in readmissions, costs for the hospital can

go down. The hospital would not be losing money on costly readmissions that can be prevented

since the hospital absorbs more of the cost for each readmission. Ways to help express the

benefits from the teach-back method to stakeholders is by charts or graphs. Once all of the

information is gathered over the first year of implementation, it will be put into a software

program to analyze information and demonstrate if the teach-back method is making a change in

the hospital and saving money.

Everything mentioned above includes the big test of change over 6 months to 1 year. The

small test of change that will be implemented in January 2012 will be over the course of 3

months. The evaluation process will be the same with the use of the questionnaires, but follow

up will be on a shorter time frame. Evaluation of the patient will begin from admission and end

30 days after discharge. Just like in the big test of change, the small test will include data

interpretation done by a software program to see if the intervention made a significant

difference.

In the small test of change, once a patient is admitted to the cardiac floor and agrees to

participate in this project, they will be given the self-efficacy questionnaire. After that survey is

32


completed teaching will occur. A couple of weeks after discharge the patient will be called and

questions from the SE questionnaire. This will give some time for the information to be

absorbed and hopefully retained. The two surveys will have the answers added up and compiled

into the software program. The expected outcome of the two surveys should yield higher scores

in the post-teaching questionnaire. This would show that the teach-back method prepares

patients with more knowledge and how to live a higher quality of life with heart failure.

After the teaching has taken place and the patient is discharged, the follow up

questionnaires will be done. The MLHFQ will show how the patient’s quality of life has been

affected due to the heart failure and if the teaching has given the patient enough knowledge to

prevent it from affecting them. The questionnaires will be done over a phone conversation about

1-2 weeks after discharge. This will also allow them to have ample time to get used to their new

diagnosis and see if any questions arise. It will also allow enough time for any complications

from the heart failure to arise due to possible lack of knowledge. If complications arise, the

MLHFQ score will be higher and show decreased quality of life. However, over this time period

if no complications have arisen, the score will be lower and quality of life will be higher. In

order to check readmission rates, the daily census will be monitored for patients that participated

in the teaching. The census will be monitored for thirty days and will show if any of these

patients have been readmitted under this diagnosis.

Timeline and Budget

In order for the small test of change to take place and provide accurate results, a timeline

and budget should be prepared and adhered to. The timeline will range from the gathering of

baseline information showing a need for improvement to the end of the small test of change.

Beginning in August 2011, a problem was noticed within the facilities heart failure readmission

33


rate average, and data was collected. The data that was collected was heart failure readmission

rates and reasons for why these readmissions were occurring. In September 2011, a reason for

the problem was narrowed down; therefore, an intervention was researched and assessment tools

formed. The teach-back method is the intervention to be implemented while using the self-

efficacy and MLHF questionnaires as tools. Starting in October 2011, through the end of the

small test of change, meetings will be held with the case manager and nurse manager of the

cardiac floor on 2 north. These meetings will involve discussion about the intervention, how

long the intervention is going to last, who is involved, and what outcomes that will be looked

for.

In February 2012, the small test will begin, and patients will be selected for intervention.

Throughout February 2012, patients will be taught using the teach-back method, and data will be

collected on the results of the intervention. Data will be collected through the use of the self-

efficacy questionnaire as mentioned above. From February 2012 to March 2012, follow up data

will be collected using the MLHF questionnaire. Data will be collected based upon discharge

date from the hospital and will be done 2 weeks post discharge. In March 2012, data from the

questionnaires will be analyzed and reviewed for signs of progress. Once all of the data is

analyzed, it will be presented to show potential benefits that could possibly be ascertained. For

further information regarding the timeline for this small test, see appendix B.

A proposed budget for this small test of change is minimal. Financial concerns would

come from the money that would need to be spent on paper for the information and

questionnaires. For one box of paper it would cost $40, and one box would suffice for the small

test of change. The other expense would be binders that contain the information and will be sent

home with the patient. The binders would cost $10 for a pack of 25, and the project would

34


Write retrospective now


include 10-20 patients. The time spent is done solely by the researcher and would have no

bearing on hourly wages. The total budget for this small test of change would be $50, which is

nothing, compared to the possibility of an improved teaching strategy for heart failure patients.

Findings and Discussion

After everything was prepped and planned out, the small test of change was implemented

and these are the findings. The results that were portrayed from this project had an overall

increase in knowledge of CHF and a better QOL from being able to comprehend and use this

knowledge. The actual findings almost doubled in physical knowledge of CHF and their new

diagnosis had little affect on the persons QOL. While questioning the patient on the phone call

they were also asked if they had any readmissions into the hospital since discharge. There was

not one single patient in the project that had a readmission for CHF or any medical condition.

The graph below depicts the results that were achieved in the small test of change pertaining to

overall knowledge through the use of the SE questionnaire.

0

5

10

15

20

25

30

35

21

10.99.3

32.8

20.5 20.7

Self- Efficacy Questionnaires

Pre Questionnaire Post Questionnaire

Daily Activities Recognition and Treat Caring for Oneself

The graph shows that in each category of the SE questionnaire, there has been a

35


Don’t word so lightly which is minimal compared to cost savings expected in readmission prevention


significant change. In the first group of questions, daily activities, there was a total possible score

of 40. The other two groups of questions, recognition and treat and caring for oneself, had total

possible scores of 24. In daily activities, the average score increased from 21 to 32.8. For

recognition and treat, the score went from 10.9 to 20.5. In caring for oneself, the average

increased from 9.3 to 20.7. All of the scores represent that the teach-back method had a

significant impact in the way the material was taught and retained by the patient. These numbers

are a representation of overall scores that could be ascertained from the answering of the

questionnaires. As depicted above the outcomes from the teach-back were successful in helping

people retain the information of what they need to be doing to maintain optimal health. All SE

scores are significant for p < .05.

Table 1 (NYHA Class 1)

MLHFQ ResultsAge Number in Group Mean Score>49 7 21<50 8 19.50Sex Number in Group Mean Score

Male 9 20.67Female 6 19.50

As for the MLHFQ, the scores were based on a total score of 105. When all of the

patients that were involved in the project were asked the questions from this particular

questionnaire, they had an average score of 20. In the table depicted above, the male participants

had an average score of 20.7 while the females had a score of 19.5. They were also grouped by

age with one group being less than or equal to 49 and the other greater than or equal to 50. The

36


Indicate paired t-test analyses…


younger group had an average score of 21 while the older group was slightly less at 19.50. There

is no real significant difference in the data by age or gender. All of the patients that participated

however, had a New York Heart Association classification class I. With the patients being in this

class, the scores were expected to be low but now this can serve as a base for these patients and

see how they maintain their QOL in the future.

Recommendations for Future

This project could go forward from here with improvements to hopefully expand hospital

wide. Some improvements that could be made are more research on the teach-back method

pertaining to more topics other than CHF and trying to get more people into this research group.

If other topics are looked at and researched then there could be other ways learned to express the

harder material that was not covered as well. One topic that could be researched is diabetes since

it too is a hard topic to teach. Also, getting more people into the research group can help

influence more people to live a higher quality of life. This is one of the problems that the facility

has now, which is getting people into their CHF program. If the program is good but nobody is

willing to participate then it is almost unsuccessful. One way to possibly increase the number of

people in the program is to add an incentive for joining and maintaining good results. Once the

numbers in the program increase then the number of CHF readmissions will hopefully decrease.

Another improvement to the implementation process is increasing the amount of material

that is given to the patient. Since everybody learns a different way, then increasing the amount

of handouts can help those that are visual learners. The handouts will also be something good

for the patient to be able to look back on if nobody is around and they have a question. Another

improvement is performing the teaching over a couple of days, which might help increase

knowledge retention. If the material is broken up into two major sections and taught on different

37


This could be a component of your education going forward and included in evaluation…


Write more formally


days then they might not be as overwhelmed. This would also allow for questions to be

answered on the material from the first day.

The project that I implemented into the hospital I believe would be an important method

to integrate fully at any facility that deals with CHF. The program would be a great way to teach

people with open-ended questions and get their thoughts on what they should be doing. The

teach-back method is a strong way to reinforce complicated information that is hard for even a

competent person to understand. It allows for a person to reiterate new information learned to a

teacher and have them judge whether or not the answer was acceptable enough to go one with

more teaching. Also, this reiteration allows for the patient to think about what is going on with

what they are saying and make them eventually comprehend it better. If they do not understand it

when they repeat it then it allows them to ask more questions about particular topics related to

their heart failure.

Conclusion

Evidence-based practice is a vital component for the advanced practice nurse. As a nurse

moves onto becoming an advanced practice nurse they will have more responsibility put in front

of them. They will go from the one assessing a response from a new medication to the one who

is diagnosing the problem and putting that patient on the new medication. This is a lot of

responsibility that will be handed down and if not prepared, mistakes can be made. The material

that is being learned from EBP will help guide the advanced practice nurse through this

responsibility and help them look for new treatment options such as the teach-back method.

I believe this project to have been a success and show that the teach-back method could

be a proven way to carry out discharge teaching. With this project, I have learned how to

research evidence on a topic and compile it to make a possible intervention in the medical field.

38


Don’t use first person in formal writing. Just state your thoughts


Not only will it allow one to make an intervention but it gives the possibility of tracking ones

care and help lead them to live a better lifestyle. I also learned how to teach patients in a more

in-depth way with material and ask open-ended questions, as to not get the typical yes or no.

This will help my role as an advanced practice nurse by allowing me to communicate more

freely with the patients that I come in contact with. Another lesson I have learned is how to

compile a team for the task at hand. When a task presents itself, being able to surround yourself

with the proper team will make all the difference in how the outcome of the task is. This is by

far one of the more important things I have learned, since I want to do the best job possible in my

career as an advanced practice nurse.

39


References

Armbrister, K. A. (2008). The Nurse Practitioner. LippincottWilliams & Wilkins.

doi:10.1097/01.NPR.0000339206.36478.0f

Britz, J. A. & Dunn, K. S. (2010). Self-care and quality of life among patients with heart failure.

Journal of the American Academy of Nurse Practitioners, 22, 480–487.

doi: 10.1111/j.1745-7599.2010.00538.x

Doody, C. M., & Doody, O. (2011). Introducing evidence into nursing practice: using the IOWA

model. British Journal of Nursing (BJN), 20661-664. Retrieved from EBSCOhost.

Institute for Clinical Systems Improvement (ICSI). Heart failure in adults. Bloomington (MN):

Institute for Clinical Systems Improvement (ICSI); 2009 Dec. 95 p. [168 references]

Horwitz, L., & Krumholz, H. (2011). Heart failure self management. Up to Date , Retrieved from

http://www.uptodate.com/contents/heart-failure-self-management?

source=search_result&selectedTitle=13%7E150

Krumholz, H. M., Amatruda, J., Smith, G. L., Mattera, J. A., Roumanis, S. A., Radford, M. J.,

Crombie, P., & Vaccarino, V. (2002). Randomized trial of an education and support

intervention to prevent readmission of patients with heart failure. Journal of the

American College of Cardiology, (39)1. Retrieved from

http://content.onlinejacc.org/cgi/reprint/39/1/83.pdf

40



Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in Nursing and

Healthcare. A Guide of Best Practice.2nd Ed. Philadelphia: Williams, & Wilkins.

Morrow, D., Clark, D., Wanzhu, T., Jingwei, W., Weiner, M., Steinley, D., & Murray, M., D.

(2006). Correlates of health literacy in patients with chronic heart failure. The

Gerontological Society of America, 46(5), 669-676. Retrieved from

gerontologist.oxfordjournals.org

Nash, D. B., Reifsnyder, J., Fabius, R. J., & Pracilio, V. P. (2011). Population Health . Sudbury,

MA: Jones and Bartlett.

Orem, D.E. (1991). Nursing: Concepts of practice (4th ed.). St. Louis, MO: Mosby-Year Book

Inc.

Smeulders, E. S. T. F., Van Haastregt, J. C., Ambergen, T., Uszko-Lencer, N. H., Janssen-

Boyne, J. J., Gorgels, A. P., Stoffers, H. E., Lodewijks-van der Bolt, C. L., Van Eijk, J. T.

& Kempen, G. I. (2010). Nurse-led self-management group programme for patients with

congestive heart failure: Randomized controlled trial. Journal of Advanced Nursing,

66, 1487–1499. doi: 10.1111/j.1365-2648.2010.05318.x

Wilson, F. L., Baker, L. M., Nordstrom, C. K., & Legwand, C. (2008).Using the teach-back and

orem's self-care deficit nursing theory toincrease childhood immunization

41


communication among low-incomemothers. Issues in Comprehensive Pediatric Nursing,

31(1), 7-22. doi:10.1080/01460860701877142

Mitchell, S. (2011, October 10). Personal Interview.

Roeman, A. (n.d.). Retrieved April 8, 2012 from http://avera.org/pdf/avera-events/E%20%20-

%20%20Care%20Transitions.pdf

42


Appendix A

Britz, J. A. & Dunn, K. S. (2010). Self-care and quality of life among patients with heart failure. Journal of the American Academy of Nurse Practitioners, 22, 480–487. doi: 10.1111/j.1745-7599.2010.00538.x

LOE - IV

Purpose - to see if there was any relevance between self-care deficits and quality of life in people that were recently hospitalized for heart failure.

Design - Descriptive correlational

Population – Adults with an admitting diagnosis of heart failure

Sampling method and size – 30 conveniently selected people

Method – Questionnaires

Outcomes Measured – They were the relationships between demographic variables, self-care maintenance, self-care management, self-care confidence, total self-care scores, physical quality of life, emotional quality of life, and total quality of life scores.

Major findings- female patients having higher scores

- Older patients having higher quality of life scores than younger participants

- The more self-care abilities a person has the better quality of life the person lives

- Showed strategies patients used for self-care of their condition including a pill counter, checking swelling and daily weight

- Confidence in self-care had a direct correlation with total, physical, and emotional quality of life.

Weaknesses:- The sample size was small and 63% were male

- The group had small geographic

- Only one hospital was used and the only means of data collection was a questionnaire

- It was subjective evidence.

Strengths:- It had strong inclusion and exclusion criteria

Significance to project:- Implies that self-care deficits decrease quality of life therefore

43


leading to worsening of chronic conditions.

- Ways to improve self-care strategies to improve quality of life.

- Implies that education for self-care is very important for one’s overall health and well-being.

Smeulders, E. S. T. F., Van Haastregt, J. C., Ambergen, T., Uszko-Lencer, N. H., Janssen-Boyne, J. J., Gorgels, A. P., Stoffers, H. E., Lodewijks-van der Bolt, C. L., Van Eijk, J. T. & Kempen, G. I. (2010). Nurse-led self-management group programme for patients with congestive heart failure: Randomized controlled trial. Journal of Advanced Nursing, 66, 1487–1499. doi: 10.1111/j.1365-2648.2010.05318.x

Purpose - to observe the effects of a self-maintenance program on psychosocial attributes, self-care behaviors and quality of life in patients that have congestive heart failure and physical activity limitations.

Design - Randomized controlled trial

Population - adults with congestive heart failure.

Sampling method and size – 317 patients, 131 of the participants were randomized to the control group to receive usual care and 186 were randomized to the usual care plus the self-management

Major findings - improvements in symptom management, self-care behavior, and quality of life.

- Improve physical activity in those with congestive heart failure.

Weakness:- not extensive enough and not long enough to show any long term effects.

- Physical testing was not used to determine outcomes of participants at the end of the study rather self-reports were used which could be skewed.

44


LOE – II RCT program. The program was designed to teach participants medical, social, and emotional self-management skills over a 21-class period. Some skills included goal setting and action planning.

Outcomes Measured – Symptom management, self-care behavior, and quality of life

- It was only conducted in the Netherlands.

Strengths:- RCT with large enough sample size for longitudinal follow-up.

- It used a large number of participants.

- It was short but had short term results.

Significance:- Showed that self-management programs can increase quality of life and physical activity in patients with congestive hear failure.

- The importance and need for more follow up care and

45


education after discharge from a hospital.

Morrow, D., Clark, D., Wanzhu, T., Jingwei, W., Weiner, M., Steinley, D., & Murray, M., D. (2006). Correlates of health literacy in patients with chronic heart failure. The Gerontological Society of America, 46(5), 669-676. Retrieved from gerontologist.oxfordjournals.org

LOE - V

Purpose - to determine the health literacy in middle to older adults including topics of cognitive and sensory abilities, education, health and demographic variables.

Design – Descriptive

Population – Adults with CHF and taking one medication pertaining to CHF

Sampling method and size – 314 conveniently selected adults

Methods – A questionnaire

Outcomes Measured -A tool named the Short Test of Functional Health Literacy in Adults (STOFHLA) was also done for the study for baseline evaluation. Included with the tests were sensory tests to assess the level of function for each participant, they included visual acuity, auditory,

Major findings –- Scores for STOFHLA were lower for those that were African American, male, older, less educated, and more comorbidities.

- Health literacy is drastically affected with age, education, and cognitive ability. Sensory tests were not as useful in predicting health literacy.

Weakness:- The sample was generated from only one hospital in the same geographic region which could lead to bias for not having a diverse group of participants.

- Nearly half of the participants in the group were African American 48% which doesn’t allow for an average depiction of races.

- The tool may underestimate cultural contributions.

- Low level of evidence.

46


speech comprehension, and verbal working memory.

Strengths:- Data collection was used appropriately with different tests done to determine a participant’s ability.

- This is a valid source for determining health literacy in a patient.

- Fairly large sample size.

Significance:- Health literacy could play a vital role in decreasing readmissions and health outcomes.

- Discharge planning should be kept simple but still give all the information one needs to

47


implement self-care.

Wilson, F. L., Baker, L. M., Nordstrom, C. K., & Legwand, C. (2008).Using the teach-back and orem's self-care deficit nursing theory toincrease childhood immunization communication among low-incomemothers. Issues in Comprehensive Pediatric Nursing, 31(1), 7-22. doi:10.1080/01460860701877142

LOE- IV

Purpose - to assess the relationship between health literacy and the ability to comprehend and communicate information with the use of the teach-back method.

Design – Quantitative-qualitative descriptive research

Population – Adult mother with at least one child

Sampling method and size – 30 conveniently selected women

Method – Questioning after material on two viruses were taught

Outcomes Measured – How health literacy along with teaching improves comprehension of informationAlso to see if the teach-back method improved overall remembrance of information

Major Findings – The teach-back method made more mothers give correct answers on risks and benefits for certain vaccines.

- The lower the literacy level the more incorrect or partially correct the answers were.

- Along with low literacy is low vocabulary which makes it harder to understand critical concepts, therefore health information should be written at a lower reading level

Weaknesses :- Low evidence level

- Sample size was small

- Only performed the study at one clinic

- Only sampled low level literacy individuals, there were no women with a higher level of literacy sampled

Strengths:- This is a valid source for determining how literacy plays a role in comprehension of material involving health information

- Data collection was compiled into

48


tables for easier comprehension

Significance:- Implies that health literacy plays an important role in understanding health related information therefore when teaching strategies they should be on more of a basic level.

- Teach-back is a plausible method for increasing memory of health related information.

Armbrister, K. A. (2008). The Nurse Practitioner. LippincottWilliams & Wilkins. doi:10.1097/01.NPR.0000339206.36478.0f

LOE - VII

Purpose - this article was opinion based and gave information regarding self-management strategies.

No design only opinion

Major Findings – Seven skills that can help improve patient’s outcomes.Current patient teaching only focuses on usual treatment and is not individualized

Weaknesses :- Level of evidence is very weak with this being primarily opinion.

Strengths:- There were good

49


recommendations for self-management strategies.

Significance:- Gives possible recommendations towards teaching points for patients.

Krumholz, H. M., Amatruda, J., Smith, G. L., Mattera, J. A., Roumanis, S. A., Radford, M. J., Crombie, P., & Vaccarino, V. (2002). Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. Journal of the American College of Cardiology, (39)1. Retrieved from http://content.onlinejacc.org/cgi/reprint/39/1/83.pdfLOE - II

Purpose - to see what kind of teaching could be done to decrease hospital readmission and mortality rate.

Design – RCT

Population – Adults with heart failure and age 50 or older

Sampling method and size – 88 patients with 44 randomly assigned to the intervention group and 44 with usual care.

Method – Teaching patients after discharge and following up with them through out the year by phone calls.

Outcomes Measured - Hospital readmission rates for CHF or any other diagnosis and

Major Findings – Readmission rates for any medical reason were 39% less in the intervention group.

- There was a 47% decrease in readmission rates for CHF.

- Proper teaching and follow-up can lead to less readmission rates and less mortality

Weaknesses:- Small sample size

- Only used patients from one hospital

Strengths:- Level of evidence was strong, RCT.

- Length of the study was adequate with following patients for a year.

- Strong inclusion and exclusioncriteria

50




death rates. Significance:- Proper teaching and knowledge towards patients with CHF can decrease readmission rates

- One on one communication between educator and patient helps the patient retain more information.

- Intermittent follow-up with patients to reassure education decrease hospital readmissions

51


Institute for Clinical Systems Improvement (ICSI). Heart failure in adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2009 Dec. 95 p. [168 references]

LOE - II

Purpose - to provide recommendations for healthcare workers to use in order to decrease hospital readmissions, properly identifying patients with heart failure, improve patient education.

Design – Clinical Practice Guideline

Population – Adults, 18 and older with heart failure that required hospitalization.

Sampling method and size – Researched different articles including RCTs, cohort studies, case-control studies, and cross-sectional studies.

Method – Used meta-analysis and systematic reviews to analyze the evidence.

Major Findings –- Recommendations that include diagnosing heart failure to the treatment of heart failure to try and keep people from being readmitted.

- Ex. Daily weights are a sign of fluid retention and important for controlling heart failure.

Weakness:- The target population was very broad.

Strength:- Used different levels of evidence to compile research

- Used meta-analysis and systematic review for analyzing evidence.

Significance:- Has a valid point to managing heart failure by self-management.

- Gives strategies towards decreasing hospital readmission

Roeman, A. (n.d.). Retrieved April 8, 2012 from http://avera.org/pdf/avera-events/E%20%20-%20%20Care%20Transitions.pdf

LOE - V

Purpose – to assess how well the teach-back method is implemented on patients by reassessing knowledge level on the information taught and readmission rates.

Design – Interventional study

Population – Adults admitted with CHF

Sampling method and size – 259 people chosen with 100 enrolled in the teach-back method and 159 not enrolled but still followed.

Major Findings- Readmission rates decreased for those that were taught by the teach-back method.5% readmission rate for those enrolled11% for those not enrolled

Weakness – Strength of the study, pilot project

Strength – There was a big sample size.Physical testing was used to determine outcome of project.

Significance – Implies

52


Method – Questions from the teaching and follow up phone calls

Outcomes Measured – See how well the teach-back method increased overall knowledge and decreased readmission rates

Knowledge was increased through the method. Scores went up from previous answers.

that the teach-back method can be used to increase health literacy and decrease readmission rates

53


Appendix B

Action Item Who When Data Collected CommentsObtain baseline dataNeeds Assessment

W Saliski August 2011 BMCS HF and HF RA Rates

Readmission Reasons and Rates?Talk with Stephanie Mitchell – Case ManagerTeresa Weaver – 2North Nurse Manger

Research Intervention andForm Assessment Tools

W Saliski August 2011 - Teach-Back

- Self-Efficacy (SE)

- MLHFQ

Implementation Plan

Two questionnaires- one for pre-post teaching

Other for post discharge

Educate staff/notify them of project

W Saliski October 2011 – end of small test

Education Discuss with 2North Case Manager – Stephanie MitchellNurse Manager – Teresa Weaver

Small Test of ChangeCollect pre-project data

Begin Patient Selection

Collect Data – Inpatient - Pre-Teaching Questionnaire (SE) - Teach Patients – Teach-Back

Follow up – After Discharge - Questionnaire – Phone Calls (MLHFQ) - Post-Teaching Questionnaire (SE)

W SaliskiAugust –November 2011

February 2012

February 2012

March 2012

- Information Letter and Informed Consent- Questionnaire results

- Questionnaire results

Readmission rates

Evaluate teaching strategy throughout to see if different approaches to topics work better.

54


Analyze Data W Saliski March 2012 Cumulative Answers

SPSS Analysis (computer software)

Present Findings W Saliski May 2012 Small Test of Change

Poster/Power Point Presentation

HF- heart failure, RA – readmission, MLHFQ – Minnesota Living with Heart Failure Questionnaire, SE – Self-Efficacy, SPSS – statistical package for social sciences

Appendix C

55


MINNESOTA LIVING WITH HEART FAILURE QUESTIONNAIRE

The following questions ask how much your heart failure (heart condition) affected your life during the past month (4 weeks). After each question, circle the 0, 1, 2, 3, 4 or 5 to show how much your life was affected. If a question does not apply to you, circle the 0 after that question.

Did your heart failure prevent

you from living as you wanted during Very Very

the past month (4 weeks) by - No Little Much

1. causing swelling in your ankles or legs? 0 1 2 3 4 52. making you sit or lie down to rest during the day? 0 1 2 3 4 53. making your walking about or climbing stairs difficult? 0 1 2 3 4 54. making your working around the house or yard difficult? 0 1 2 3 4 55. making your going places away from home difficult? 0 1 2 3 4 56. making your sleeping well at night difficult? 0 1 2 3 4 57. making your relating to or doing things with your friends or family difficult? 0 1 2 3 4 58. making your working to earn a living difficult? 0 1 2 3 4 5 9. making your recreational pastimes, sports

56


or hobbies difficult? 0 1 2 3 4 510. making your sexual activities difficult? 0 1 2 3 4 511. making you eat less of the foods you like? 0 1 2 3 4 512. making you short of breath? 0 1 2 3 4 513. making you tired, fatigued, or low on energy? 0 1 2 3 4 514. making you stay in a hospital? 0 1 2 3 4 515. costing you money for medical care? 0 1 2 3 4 516. giving you side effects from treatments? 0 1 2 3 4 517. making you feel you are a burden to your family or friends? 0 1 2 3 4 518. making you feel a loss of self-control in your life? 0 1 2 3 4 5 19. making you worry? 0 1 2 3 4 520. making it difficult for you to concentrate or remember things? 0 1 2 3 4 5 21. making you feel depressed? 0 1 2 3 4 5_________________________________________________________________________

©1986 Regents of the University of Minnesota, All rights reserved. Do not copy or reproduce without permission. LIVING WITH HEART FAILURE® is a registered trademark of the Regents of the University of Minnesota.

Self-Efficacy Questionnaire (SE)

57


All answers are confidential.

SECTION A:

Listed below are common instructions given to persons with heart failure. How routinely do you do the following?

Never or rarely

Sometimes Frequently Always or daily

1. Weigh yourself? 1 2 3 4

2. Check your ankles for swelling? 1 2 3 4

3. Try to avoid getting sick (e.g., flu shot, avoid ill people)?

1 2 3 4

4. Do some physical activity? 1 2 3 4

5. Keep doctor or nurse appointments?

1 2 3 4

6. Eat a low salt diet? 1 2 3 4

7. Exercise for 30 minutes? 1 2 3 4

8. Forget to take one of your medicines?

1 2 3 4

9. Ask for low salt items when eating out or visiting others?

1 2 3 4

10.Use a system (pill box, reminders) to help you remember your medicines?

1 2 3 4

58


SECTION B:

Many patients have symptoms due to their heart failure. Trouble breathing and ankle swelling are common symptoms of heart failure.

In the past month, have you had trouble breathing or ankle swelling? Circle one.

0) No

1) Yes

11. If you had trouble breathing or ankle swelling in the past month… (circle one number)

Have not had

these

I did not recognize it

Not Quickly

Somewhat Quickly

Quickly Very Quickly

How quickly did you recognize it as a symptom of heart failure?

N/A 0 1 2 3 4

Listed below are remedies that people with heart failure use. If you have trouble breathing or ankle swelling, how likely are you to try one of these remedies?

(circle one number for each remedy)

59


Not Likely Somewhat Likely

Likely Very Likely

12.Reduce the salt in your diet 1 2 3 4

13.Reduce your fluid intake 1 2 3 4

14.Take an extra water pill 1 2 3 4

15.Call your doctor or nurse for guidance

1 2 3 4

16. Think of a remedy you tried the last time you had trouble breathing or ankle swelling,

(circle one number)

I did not try anything

Not Sure Somewhat Sure

Sure Very Sure

How sure were you that the remedy helped or did not help?

0 1 2 3 4

SECTION C:

In general, how confident are you that you can:

Not Confident

Somewhat Confident

Very Confident

Extremely Confident

17.Keep yourself free of heart failure symptoms?

1 2 3 4

60


18.Follow the treatment advice you have been given?

1 2 3 4

19.Evaluate the importance of your symptoms?

1 2 3 4

20.Recognize changes in your health if they occur?

1 2 3 4

21.Do something that will relieve your symptoms?

1 2 3 4

22.Evaluate how well a remedy works?

1 2 3 4

61

Documents

wpsaliskicrnp.weebly.comwpsaliskicrnp.weebly.com/uploads/2/7/7/8/27788745/e… · Web viewImproving Self-Management of Heart Failure with APN Education . William P Saliski . Auburn