The role of health literacy, depression, disease knowledge, and self-efficacy in self-care among adults with heart failure: An updated model.

BACKGROUND: Patients with inadequate health literacy and heart failure face high healthcare costs, more hospitalizations, and greater mortality. To address these negative consequences, patients need to improve heart failure self-care. Multiple factors may influence self-care, but the exact model by which they do so is not fully understood. OBJECTIVES: The objective of this study was to examine a model exploring the contribution of health literacy, depression, disease knowledge, and self-efficacy to the performance of heart failure self-care. METHODS: Using a cross-sectional design, patients were recruited from a heart failure clinic and completed validated assessments of their cognition, health literacy, depression, knowledge, self-efficacy and self-care. Patients were separated into two groups according to their health literacy level: inadequate/marginal and adequate. Differences between groups were assessed with an independent t-test. Hypothesized paths and mediated relationships were estimated and tested using observed variable path analysis. RESULTS: Participants (n = 100) were mainly male (67%), white (93%), and at least had a high school education (85%). Health literacy was associated with disease knowledge (path coefficient=0.346, p = 0.002), depression was negatively associated with self-efficacy (path coefficient=-0.211, p = 0.037), self-efficacy was positively associated with self-care (path coefficient=0.402, p<0.0005), and there was evidence that self-efficacy mediated the link between depression and self-care. There was no evidence of: mediation of the link between health literacy and self-care by knowledge or self-efficacy; positive associations between knowledge and self-efficacy or self-care; or mediation of the disease knowledge and self-care relationship by self-efficacy. Further, depression was associated with self-care indirectly rather than also directly as hypothesized. CONCLUSIONS: Self-efficacy and depression are associated with heart failure self-care. Data generated from the model suggest that healthcare professionals should actively engage all patients to gain self-efficacy and address depression to positively affect heart failure self-care.

Evaluation of a nursing and pharmacy student educational activity promoting interprofessional learning.

BACKGROUND: Nurses and pharmacists are essential healthcare team members and must collaborate to provide safe and effective patient care. The purpose of this study was to evaluate nursing and pharmacy student views on interprofessional collaboration after completing an educational activity. INTERPROFESSIONAL EDUCATION ACTIVITY: Students participated in an interprofessional activity designed to improve empathy toward older adults and completed an open-ended questionnaire post-activity regarding their experience and views on interprofessional collaboration. Content analysis identified themes grounded in the responses. Students (n = 216) felt communication needed improvement (n = 31, 16.8%), were frustrated with fragmented care (n = 31, 16.8%), found interprofessional collaboration necessary (n = 37, 20.1%), and enjoyed the interprofessional experience (n = 17, 9.2%). DISCUSSION: Study results provide evidence for the inclusion of additional structured interprofessional activities into all health professions curriculum to emphasize collaboration, improve communication, and modify views in preparation for interprofessional practice.

Psychometric Testing of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI).

Although coronary heart disease (CHD) requires a significant amount of self-care, there are no instruments available to measure self-care in this population. The purpose of this study was to test the psychometric properties of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI). Using the Self-Care of Chronic Illness theory, we developed a 22-item measure of maintenance, management, and confidence appropriate for persons with stable CHD and tested it in a convenience sample of 392 adults (62% male, mean age 61.4 ± 9.6 years). Factorial validity was tested with confirmatory factor analysis. Convergent validity was tested with the Medical Outcomes Study MOS-SAS Specific Adherence Scale and the Decision Making Competency Inventory (DMCI). Cronbach alpha and factor determinacy scores (FDS) were calculated to assess reliability. Two multidimensional self-care scales were confirmed: self-care maintenance included "consultative behaviors" (e.g., taking medicines as prescribed) and "autonomous behaviors" (e.g., exercising 30 minute/day; FDS = .87). The multidimensional self-care management scale included "early recognition and response" (e.g., recognizing symptoms) and "delayed response" (e.g., taking an aspirin; FDS = .76). A unidimensional confidence factor captured confidence in each self-care process (α = .84). All the self-care dimensions were associated with treatment adherence as measured by the MOS-SAS. Only self-care maintenance and confidence were associated with decision-making (DCMI). These findings support the conceptual basis of self-care in patients with CHD as a process of maintenance that includes both consultative and autonomous behaviors, and management with symptom awareness and response. The SC-CHDI confidence scale is promising as a measure of self-efficacy, an important factor influencing self-care. © 2016 Wiley Periodicals, Inc.

Psychometric Testing of the Self-care of Hypertension Inventory.

BACKGROUND: Hypertension (HTN) is a global public health issue. Self-care is an essential component of HTN treatment, but no instruments are available with which to measure self-care of HTN. OBJECTIVES: The purpose of this study is to test the psychometric properties of the Self-care of Hypertension Inventory (SC-HI). METHODS: Using the Self-care of Chronic Illness theory, we developed a 24-item measure of maintenance, monitoring, and management appropriate for persons with chronic HTN, tested it for content validity, and then tested it in a convenience sample of 193 adults. Exploratory factor analysis was used to identify measure structure. Cronbach's α and factor determinacy scores and were used to assess reliability. Validity was tested with the Medical Outcomes Study General Adherence Scale and the Decision Making Competency Inventory. RESULTS: Seventy percent of the sample was female; mean age was 56.4 ± 13 years; mean duration of HTN was 11 ± 9 years. Removal of 1 item on alcohol consumption resulted in a unidimensional self-care maintenance factor with acceptable structure and internal consistency (α = .83). A multidimensional self-care management factor included "consultative" and "autonomous" factors (factor determinacy score = 0.75). A unidimensional confidence factor captured confidence in and persistence with each aspect of self-care (α = .83). All the self-care dimensions in the final 23-item instrument were associated with treatment adherence and several with decision making. CONCLUSION: These findings support the conceptual basis of self-care in patients with HTN as a process of maintenance, monitoring, and management. The SC-HI confidence scale is promising as a measure of self-efficacy in self-care.

Health-Related Quality of Life in Heart Failure Patients With Varying Levels of Health Literacy Receiving Telemedicine and Standardized Education.

The purpose of this study was to examine the effect of telemonitoring plus education by home healthcare nurses on health-related quality of life in patients with heart failure who had varying health literacy levels. In this pretest/posttest treatment only study, 35 patients with a diagnosis of heart failure received home healthcare nurse visits, including education and telemonitoring. Heart failure education was provided by nurses at each home healthcare visit for approximately 15 to 20 minutes. All participants completed the Short-Form Test of Functional Health Literacy in Adults (S-TOFHLA) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) during the first week of home healthcare services. The MLHFQ was administered again at the completion of the covered home healthcare services period (1-3 visits per week for 10 weeks). Most participants were older adults (mean age 70.91±12.47) and had adequate health literacy (51.4%). Almost half of the participants were NYHA Class III (47.1%). All participants received individual heart failure education, but this did not result in statistically significant improvements in health-related quality-of-life scores. With telemonitoring and home healthcare nurse visits, quality-of-life scores improved by the conclusion of home healthcare services (clinically significant), but the change was not statistically significant. Individuals with marginal and inadequate health literacy ability were able to correctly use the telemonitoring devices.

Optimum Function in Patients With Heart Failure.

PURPOSE: The aim of this article is to use Walker and Avant's methodological approach to provide clarity and a definition of optimum function as it relates to patients with heart failure (HF). BACKGROUND: Understanding optimum function in patients with HF can help advanced practice nurses (APNs) identify clinical signs of deterioration. Interpreting patient descriptions of signs and symptoms may be the first cues prior to diagnosis. DATA SOURCE: Literature searches included electronic scientific databases and a manual search. Literature from 2005 to 2013 was reviewed. Themes were searched for function. The text was limited to English language peer-reviewed articles, resulting in 43 articles and 3 books in the analysis. CONCLUSION: A definition of optimum function was developed from a synthesis of the literature's common themes. The four defining attributes include: multidimensional aspect (physical, cognitive, psychosocial, physiological, and spiritual), achieving a desired goal, dynamic and relative change (compared with previous functioning), and most favorable level of functioning. Defining optimum function in patients with HF provides clarity of patient communication to and between APNs. The concept promotes patient-centered care, enabling goal adjustment by the patient and APN. The concept analysis facilitates a deeper understanding of communication during the patient encounter.

Relationship Between Standardized Glycemic Protocols and Healthcare Cost.

Rising healthcare costs and the management of diabetes are financially straining to healthcare organizations. The study purpose was to examine whether a direct relationship existed between the cost of hospitalization, length of stay, excess admission days, and discharge blood glucose (DC-BG) levels and utilizing a standardized glycemic protocol. A retrospective cohort analysis was conducted of adult diabetes mellitus type 2 (DM-2) patients' pre-diabetic protocol (January 1, 2011-December 31, 2011) and post-diabetic protocol (August 1, 2012-October 31, 2012). The sample included DM-2 inpatients aged ≥ 18 years admitted without complications and/or with abnormal fasting blood glucose. Pre-protocol sample comprised n = 346 subjects and post-protocol sample comprised n = 149 subjects. Patients who received the diabetic protocol in 2012 experienced a decrease in the DC-BG (p < .05) and decrease in excess admission days (p < .05). Evidence supports that utilizing a standardized glycemic protocol improves glycemic control and reduces healthcare cost.

Impact of an Aging Simulation Game on Pharmacy Students' Empathy for Older Adults.

OBJECTIVE: To evaluate changes in empathy and perceptions as well as game experiences among student pharmacists participating in an aging simulation game. METHODS: First-year student pharmacists participated in an aging simulation game. Changes were measured pre/post-activity using the Kiersma-Chen Empathy Scale (KCES) and Jefferson Scale of Empathy--Health Professions Scale (JSE-HPS) for empathy and the Aging Simulation Experience Survey (ASES) for perceptions of older adults' experiences and game experiences. Wilcoxon signed rank tests were used to determine changes. RESULTS: One hundred fifty-six student pharmacists completed the instruments. Empathy using the KCES and JSE-HPS improved significantly. Of the 13 items in the ASES, 9 significantly improved. CONCLUSION: Simulation games may help students overcome challenges demonstrating empathy and positive attitudes toward elderly patients.

Impact of the Geriatric Medication Game® on nursing students' empathy and attitudes toward older adults.

BACKGROUND: Nurses should be well-prepared to improve and address health-related needs of older adults, but students may have difficulty understanding and empathizing, as they may not yet have personally experienced aging-related challenges. Simulation games can be used to help students understand the experiences of others, but limited information is available on the impact of simulation experiences on student empathy. OBJECTIVE: The objective of this study was to examine the impact of participation in an aging simulation game on nursing students' empathy and attitudes toward older adults as well as their understanding of patients' experiences in the healthcare system. DESIGN: This study used a quasi-experimental, pretest-posttest design. SETTING: A school of nursing in the Midwestern United States. PARTICIPANTS: The convenience sample included 58 sophomore-level baccalaureate nursing students. METHODS: Students played the role of an older adult during a 3-hour laboratory aging simulation game, the Geriatric Medication Game® (GMG). Students completed the (1) Kiersma-Chen Empathy Scale (KCES, 15 items, 7-point Likert-type), (2) Jefferson Scale of Empathy-Health Professions Students (JSE-HPS, 20 items, 7-point Likert-type), and (3) Aging Simulation Experience Survey (13 items, 7-point Likert-type) pre- and post-game to assess study objectives. Descriptive statistics and paired t-tests were performed in SPSS v.21.0, as the data were normally distributed. RESULTS: Students' empathy (N=58) toward older adults significantly improved overall (KCES p=0.015, JSE-HPS p<0.001). Improvements also were seen on seven out of 13 questions related to attitudes and healthcare understanding (p<0.05). In the post-test, students agreed that they experienced frustration and impatience during the GMG. CONCLUSIONS: Students may not be aware of older adults' feelings and experiences prior to experiencing aging-related changes themselves. Simulation activities, such as the GMG, can be a useful mechanism for addressing empathy and caring during student education.

The relationship between uncontrolled glycemia and the cost of hospitalization.

PURPOSE/OBJECTIVE: The purpose of this study was to examine the relationship between hospitalization cost and discharge blood glucose levels among adult diabetes mellitus type 2 patients hospitalized with uncontrolled glycemia without complications. DESIGN: Retrospective cohort analysis examined healthcare billing and laboratory data. SETTING: The study was performed in Chicago, Illinois, in a 269-bed medical center between January 1, 2011, and December 31, 2011. SAMPLE: Patients were placed into 1 of 2 groups at discharge: blood glucose level less than 250 mg/dL or blood glucose level 250 mg/dL or greater. RESULTS: Of the 579 patients with uncontrolled glycemia, 366 met inclusion criteria: diabetes mellitus without complications (International Classification of Diseases, Ninth Revision; 250.0) with abnormal fasting blood glucose (International Classification of Diseases, Ninth Revision; 790.21). Discharge blood glucose levels were 250 mg/dL or greater in 74 patients and less than 250 mg/dL in 292 patients. Mean age of the 2 cohorts was 71.4 (SD, 13.41) years. The majority was male (52.1% and 59.7%, respectively). The median healthcare cost for the entire sample was $3964.34. The mean cost of healthcare for the group with blood glucose of 250 mg/dL or greater at discharge was $4182.65, with a mean length of stay of 8.22 (SD, 3.468) days, while the mean cost of healthcare for the group with blood glucose of less than 250 mg/dL at discharge was $3826.25 and mean length of stay 7.826 (SD, 6.073) days. Analysis of cost was conducted using Pearson χ and was significant for α = .05 (P = .037). The odds ratio of having increased healthcare cost with blood glucose of 250 mg/dL or greater was 1.732 with a 95% confidence interval of 0.998 to 3.012. CONCLUSION: The group discharged with blood glucose levels of 250 mg/dL or greater accrued greater cost during hospitalization than did patients who were discharged with blood glucose levels of less than 250 mg/dL. IMPLICATIONS: Today's healthcare system is struggling with cost containment, quality control, and standardization of care. Clinical nurse specialists can evaluate current patient care practices and ensure that the practice setting is fiscally beneficial to future patients and healthcare organizations.

Relationships between health literacy and heart failure knowledge, self-efficacy, and self-care adherence.

BACKGROUND: It has been argued that only 12% of adults have the necessary health literacy to manage their health care effectively, which can lead to difficulties in self-care activities, such as medication adherence. Prior research suggests that health literacy may influence knowledge, self-efficacy and self-care, but this has not been fully examined. OBJECTIVE: To test a model to explain the relationships between health literacy, heart failure knowledge, self-efficacy, and self-care. METHODS: Prior to receiving clinic-based education, newly referred patients to 3 heart failure clinics completed assessments of health literacy, heart failure knowledge, self-efficacy, self-care, and demographics. Structural equation modeling was completed to examine the strength of the inter-variable relationships. RESULTS: Of 81 participants recruited, data from 63 patients were complete. Health literacy was independently associated with knowledge (P < 0.001). Health literacy was not related to self-care. Self-efficacy was independently-associated with self-care adherence (P = 0.016). No other relationships were statistically significant. The model had good fit (comparative fit index = 1.000) and explained 33.6% of the variance in knowledge and 27.6% in self-care. CONCLUSIONS: Health literacy influences knowledge about heart failure but not self-care adherence. Instead, self-efficacy influenced self-care adherence. Future research should incorporate additional factors that may better model the relationships between health literacy, knowledge, self-efficacy, and self-care.

Implementing shared medical appointments for heart failure patients in a community cardiology practice: a pilot study.

OBJECTIVE: To examine patient and staff satisfaction, billing charges, and programmatic feasibility of shared medical appointments (SMA) in a nurse practitioner-managed heart failure (HF) clinic in a community cardiology practice. METHODS: Twenty patients were scheduled among four SMAs for this pilot study. All aspects of a usual clinic appointment were utilized during the SMA, but an additional 20-minute teaching session was presented. All patients completed a satisfaction questionnaire. The office staff completed satisfaction questionnaires about the SMA. Billing charges, cancellations and missed appointments without cancellation for SMAs were compared to usual clinic appointment days. RESULTS: Satisfaction was high among patients and office staff. Rates for no-shows were similar for SMAs versus usual appointments (15% versus 5.5%), but there were fewer cancellations among SMAs (0% versus 28%). This may be a reflection of the personalized appointment reminder calls that were made to the patients scheduled for SMAs. Billing charges were not significantly different for SMAs versus usual appointments. CONCLUSION: SMAs are a feasible option in a community cardiology practice.

Health Literacy Influences Heart Failure Knowledge Attainment but Not Self-Efficacy for Self-Care or Adherence to Self-Care over Time.

Background. Inadequate health literacy may be a barrier to gaining knowledge about heart failure (HF) self-care expectations, strengthening self-efficacy for self-care behaviors, and adhering to self-care behaviors over time. Objective. To examine if health literacy is associated with HF knowledge, self-efficacy, and self-care adherence longitudinally. Methods. Prior to education, newly referred patients at three HF clinics (N = 51, age: 64.7 ± 13.0 years) completed assessments of health literacy, HF knowledge, self-efficacy, and adherence to self-care at baseline, 2, and 4 months. Repeated measures analysis of variance with Bonferroni-adjusted alpha levels was used to test longitudinal outcomes. Results. Health literacy was associated with HF knowledge longitudinally (P < 0.001) but was not associated with self-efficacy self-care adherence. In posthoc analyses, participants with inadequate health literacy had less HF knowledge than participants with adequate (P < 0.001) but not marginal (P = 0.073) health literacy. Conclusions. Adequate health literacy was associated with greater HF knowledge but not self-efficacy or adherence to self-care expectations over time. If nurses understand patients' health literacy level, they may educate patients using methods that promote understanding of concepts. Since interventions that promote self-efficacy and adherence to self-care were not associated with health literacy level, new approaches must be examined.

Implementing family-based childhood obesity interventions.

Family-based interventions have been effective in managing childhood obesity, and pediatric nurse practitioners (PNPs) are positioned to provide obesity interventions in both patient and family primary care settings. The purpose of this article is to guide the PNP in implementing family-based childhood obesity interventions, including identification, diagnostic evaluation, and management.

Amiodarone-induced pulmonary toxicity: case study with syndrome analysis.

Amiodarone is often prescribed for the control of atrial and ventricular arrhythmias. While generally effective, the potential for a variety of side effects is substantial. Pulmonary toxicity, leading to acute or chronic respiratory failure, manifests with cough, dyspnea, infiltrates on chest radiograph, and a potential for progression to death. Although routinely cited as an adverse effect of amiodarone, it is relatively rare in terms of statistical incidence. In an effort to shed light on this syndrome, we present a stereotypical case study in amiodarone-induced pulmonary toxicity, as a prelude to a review of theorized pathophysiology, epidemiology, clinical presentation, diagnosis, therapeutics, monitoring recommendations, and areas for future research.

Validation of an empathy scale in pharmacy and nursing students.

OBJECTIVE: To validate an empathy scale to measure empathy in pharmacy and nursing students. METHODS: A 15-item instrument comprised of the cognitive and affective empathy domains, was created. Each item was rated using a 7-point Likert scale, ranging from strongly disagree to strongly agree. Concurrent validity was demonstrated with the Jefferson Scale of Empathy - Health Professional Students (JSE-HPS). RESULTS: Reliability analysis of data from 216 students (pharmacy, N=158; nursing, N=58) showed that scores on the empathy scale were positively associated with JSE-HPS scores (p<0.001). Factor analysis confirmed that 14 of the 15 items were significantly associated with their respective domain, but the overall instrument had limited goodness of fit. CONCLUSIONS: Results of this study demonstrate the reliability and validity of a new scale for evaluating student empathy. Further testing of the scale at other universities is needed to establish validity.

The integration of an online module on student learning.

Heart failure is a prevalent and costly condition. Patients with better self-management are less likely to be rehospitalized. An online interactive heart failure module was developed and integrated into a medical-surgical nursing course to assist students in learning how to care for patients with heart failure. The purpose of this study was to examine whether the integration of an online heart failure module improved baccalaureate nursing students' heart failure self-management knowledge. A pretest/posttest design was used to examine the effects of student knowledge of heart failure self-management following implementation of an online module. Among 235 students, significant improvement of heart failure self-management knowledge was observed (P < .05). The mean posttest scores ranged from 13.82 to 15.93. Students had problems mastering knowledge of weight monitoring, use of nonsteroidal anti-inflammatory drugs, symptoms to report to physicians, and potassium-based salt substitutes. These findings were similar to four studies examining nurses' knowledge of heart failure. Students and nurses have difficulty mastering similar heart failure education concepts. An additional strategy, such as simulated or case scenarios, needs to be developed to help nurses and nursing students master all key concepts of heart failure self-management.

A qualitative analysis of coronary heart disease patient views of dietary adherence and web-based and mobile-based nutrition tools.

PURPOSE: Dietary adherence can be challenging for patients with coronary heart disease (CHD), as they may require multiple dietary changes. Choosing appropriate food items may be difficult or take extensive amounts of time without the aid of technology. The objective of this project was to (1) examine the dietary challenges faced by patients with CHD, (2) examine methods of coping with dietary challenges, (3) explore the feasibility of a Web-based food decision support system, and (4) explore the feasibility of a mobile-based food decision support system. METHODS: Food for the Heart (FFH), a Web site-based food decision support system, and Mobile Magic Lens (MML), a mobile-based system, were developed to aid in daily dietary choices. Three CHD patient focus groups were conducted and focused on CHD-associated dietary changes as well as the FFH and MML prototypes. A total of 20 CHD patients and 7 informal caregivers participated. Qualitative, content analysis was performed to find themes grounded in the responses. RESULTS: Five predominant themes emerged: (1) decreasing carbohydrate intake and portion control are common dietary challenges, (2) clinician and social support makes dietary adherence easier, (3) FFH could make meal-planning and dietary adherence less complicated, (4) MML could save time and assist with healthy choices, and (5) additional features need to be added to make both tools more comprehensive. CONCLUSION: Food for the Heart and MML may be tools that CHD patients would value in making food choices and adhering to dietary recommendations, especially if additional features are added to assist patients with changes.

Impact of the geriatric medication game on pharmacy students' attitudes toward older adults.

OBJECTIVE: To examine the impact of participation in the Geriatric Medication Game on pharmacy students' perceptions of and attitudes toward older adults and familiarity with common disabilities that affect them and the process of seeking health care. DESIGN: In the game, first-year pharmacy students "became" older adults during a 3-hour pharmacy practice laboratory. They were given aging-related challenges (eg, impaired vision or mobility) and participated as patients in simulated healthcare scenarios, such as a visit to a physician's office and a pharmacy. ASSESSMENT: After playing the game, students completed a 5-question reflection about their experiences and attitudes toward older adults. Content analysis was performed to identify themes from 4 years of student (n = 625) reflections. Predominant themes included: improved attitudes toward older adults, better understanding of patient experiences, and increased willingness to provide assistance. CONCLUSIONS: Incorporating the Geriatric Medication Game into the pharmacy curriculum may facilitate students' understanding of the challenges that older adults face and improve future interactions.