Appraisal and summarize
Instructions
Appraisal: Appraise the article in narrative format by
answering the following questions.
• What are the strengths and weaknesses of the
sampling method, as applied to this study? Give a
rationale for your claims.
◦ Be sure to consider the inclusion/exclusion
criteria, if any, and extraneous variables that the
criteria control for.
• Were the measurement instruments reliable and
valid? Why or why not?
• Was the intervention performed consistently? Why or
why not?
• Were the conclusions of the study supported by the
results? Why or why not?
◦ Consider study limitations when analyzing
conclusions with respect to results.
◦ Include key statistical results and p-values as
part of your rationale.
Summary Please look the example article, how to summarize this
article.
Conclusion: Write a conclusion that gives your analysis
of the nursing implications based on the findings of the
study.
• DO NOT just use implications to nursing from the
article; provide your own analysis.
• Take clinical significance and risk vs. benefits into
account.
1
Synopsis and Appraisal of a Study Exploring Music and Hypnotic Suggestion to Manage
Chronic Pain
Studentfirstname Studentlastname
College of Nursing, Resurrection University
NUR4440: Research in Nursing
Professor Carina Piccinini
April 13, 2020
Lukman Alaki
Lukman Alaki
Lukman Alaki
Lukman Alaki
2
Synopsis and Appraisal of a Study Exploring Music and Hypnotic Suggestion to Manage
Chronic Pain
The purpose of this paper is to summarize and appraise a research study that investigated
the effects of music and hypnotic suggestion on patients enduring chronic pain. The Center for
Disease Control and Prevention (CDC, 2016) highlighted that over 60% of drug overdose deaths
involve opioids initially prescribed for pain relief. Therefore, the CDC recommends a shift
toward non-opioid treatment that include many multimodal and multidisciplinary therapy
options. Besides reducing the cost of drug treatment and possible addiction or death, mental
stability and overall quality of life for patients in chronic pain chronic pain would be improved
for patients in chronic pain if it was managed with safer options. Although further research is
being conducted to fully understand the long-term effect of music and hypnosis on chronic pain,
currently they are both considered a method in multidisciplinary therapy.
Summary of the Study
There is a movement in medicine to look at more non-pharmacological treatments for
chronic pain due to possible dependency and the serious side effects risk. With so much interest
in the practice of mind-body interventions, there has already been evidence that shows hypnosis
and music are effective separately for patients in pain, but there is no research on combining the
two interventions for a better outcome. This study addresses that gap by testing the interventions
together.
Johnson et al. (2017) conducted a quasi-experimental study to explore the possible
combined effect of hypnotic suggestion and music to improve components of chronic pain, pain
bothersomeness, anxiety, depression, and distress. Interventions and data collection took place
in the homes of the participants.
Commented [CP1]: This answers “Why is this important
to study?” It’s not just testing out a new intervention…it
goes beyond that to fatalities through the pharmacological
methods that have led to an opioid crisis and finding
solutions for chronic pain management.
The CDC and other healthcare related organizations are
great sources of information on the importance of topics.
Commented [CP2]: What is known (we need new non-
pharm methods, music and hypnosis work separately), not
known (do music and hypnosis work better in combo?), and
gap in knowledge (to test the combo).
This information is found in the introduction to every
research article. DO NOT use the discussion/conclusions
section of an article for this information! It will be WRONG
Commented [CP3]: Study being summarized/appraised is
correctly cited.
Specific research design stated.
Setting of study stated.
3
The researchers acquired their samples through a nonrandom snowball sample, where
participants were first referred by physicians from an integrative cancer center in Texas. Later,
patients self-enrolled—a volunteer/convenience sampling method—due to difficulties with
enlisting participants through referral. Twelve participants originally enrolled under the inclusion
criteria of anyone over the age of 18 who was English or Spanish speaking, diagnosed with
cancer or other serious illness, and rated their pain > 4 on an 11-point numerical rating scale.
Two participants were lost to follow up, with a final sample size of 10. The average age of the
participants was 58.3 years, with most of the participants being white (75%), women (67%),
married (58%) and an associate’s degree or higher (55%).
At the beginning of the study for baseline data, each participant completed a
demographic form, the Hospital Anxiety and Depression Scale (HADS), and numeric rating
scales (NRS) to assess pain, pain bothersomeness, and distress. The HADS has a score range of 0
to 42, with higher scores indicating more depression and anxiety. The NRS for the three
variables required participants to rate on a scale of 0 to 10, with 0 representing “none” and 10
representing “worst possible.” Participants were then asked to rate and document their pain daily
upon waking up, as well as before and after the intervention, for two weeks.
The three-part recorded audio intervention was provided to patients for self-
administration. First, participants listened to a 5-minute hypnotic suggestion. Then, they listened
to 15 minutes of string orchestra music (Fantasia on a Theme of Thomas Tallis by Ralph Vaughn
Williams). Finally, they listened to a post-hypnotic suggestion to continue the pain relief attempt.
Researchers called participants once per week for two weeks to discuss progress and remind
participants to record their pain and do the intervention consistently. Data on the same three
numeric ratings scales and HADS were submitted after the second week of the intervention. The
Commented [CP4]: Sampling method stated and
explained.
Inclusion criteria listed.
Exclusion criteria listed.
Loss to follow up explained.
Selected demographics reported with stats.
Commented [CP5]: Measurement instruments defined
with context to values.
When measurements were taken (in this case by the
participants with timing noted).
4
participants were also asked to complete an NRS for Treatment Satisfaction with a range of 0 to
11, with 0 representing “not satisfied at all” and 11 representing “totally satisfied.” The
researcher concluded the study with Study Completion/Dropout interviews, which was
qualitative data to verify treatment fidelity.
Appraisal
The combined snowball and volunteer/convenience sampling method may have attracted
participants that were predisposed to the effects of complementary and alternative medicine
(CAM) methods, creating a potential placebo effect on the intervention. There was no exclusion
criteria; however, a scale to measure the participants’ attitudes toward CAM and including it in
the statistical analysis would have reduced bias considerably. The participants in the sample had
multiple conditions, including musculoskeletal conditions (5), cancer (4), fibromyalgia (2), mood
disorders (3) and inflammatory conditions (3). With the wide range of illnesses, it would be
difficult to draw conclusions about the effect of the intervention on a particular illness or
disorder. For these reasons, the sampling method was not appropriate for an experimental study,
and the lack of exclusion criteria was problematic.
An NRS has been validated for pain in two previous studies, but the authors did not
mention if it has been tested for pain bothersomeness or distress. It is unknown if the scale is
reliable and valid for at least two major variables in this study, bringing into question
measurement error for them. The Treatment Satisfaction NRS has been tested for reliability and
validity in one previous study, and the HADS demonstrated internal consistency reliability with
Cronbach’s alpha scores of 0.83 and 0.84 in previous studies.
Researchers called participants once per week to remind them to adhere to the protocol,
but timing of the calls was not reported. The authors failed to report complete compliance data
Commented [CP6]: The intervention is described, with
additional post-intervention measurement tools stated and
described.
Commented [CP7]: Analysis of sampling method and
inclusion/exclusion criteria. Rationales are fully developed.
Commented [CP8]: Validity/reliability of measurement
tools stated and analyzed.
5
for collection and the intervention, but they did report that 9 of the 11 participants listened to the
audio recording multiple times a day. Due to this, treatment fidelity was compromised by
introducing a “dosing” variable that was not controlled for in the analysis.
The researchers concluded that their findings supported their hypothesis that the
combination of hypnotic suggestion and music help in the reduction of chronic pain in
participants. Each participant reported a reduction in their pain from 6.6 to 5.4, pain
bothersomeness from 7.5 to 5.4, distress from 5.9 to 4.9, anxiety from 7.2 to 6.5, and depression
from 6.1 to 4.1. The conclusion in a reduction in pain is technically correct, but no statistical
significance was calculated or reported in this study, so eliminating chance differences is
impossible. The limitations acknowledged by the authors (small sample size and not controlling
for usual care with pain medication), plus the fact that a majority of participants used the
intervention multiple times a day, means that the conclusions are not fully supported.
Conclusion
The conclusions of this study were not fully supported, but other studies cited in the
article indicate that an effect is evident. Acceptability of the combined intervention was high in
this study, and the limited medical-related cost and lack of complications imply that the
intervention is possible to recreate and practice in many hospitals, clinics, and home settings.
The practice of including hypnotic suggestion and music (possibly of the patient’s choosing and
not the prescribed classical music that some participants in this study complained about) could be
beneficial to a wide range of pain sufferers with no side effects. The study, if nothing else,
implied that patients who are invested in the idea of non-pharmacological pain reduction would
experience the benefit from the intervention. Nurses can use this study and others like it to
further explore the option of hypnosis/music recordings that they can offer to chronic pain
Commented [CP9]: Treatment fidelity explained and
analyzed.
Commented [CP10]: Conclusions analyzed with regard to
results and lack of p values, with consideration of limitations
noted by the authors.
6
sufferers, in hopes of lessening the chronic effects on their acute problems. Patients can self-
administer, reducing the burden of nursing-driven interventions on busy bedside caregivers.
Commented [CP11]: Careful balancing between lack of
conclusive evidence and relative safety and low-cost of
intervention. Specific ideas for nursing implications end the
paper.
7
References
Center for Disease Control and Prevention. (n.d.). Module 2: Treating chronic pain without
opioids. Retrieved from
https://www.cdc.gov/drugoverdose/training/nonopioid/508c/index.html
Johnson, A. J., Kekecs, Z., Roberts, R. L., Gavin, R., Brown, K., & Elkins, G. R. (2017).
Feasibility of music and hypnotic suggestion to manage chronic pain. International
Journal of Clinical & Experimental Hypnosis, 65(4), 452–465.
https://doi.org/10.1080/00207144.2017.1348858
https://www.cdc.gov/drugoverdose/training/nonopioid/508c/index.html
https://doi.org/10.1080/00207144.2017.1348858
https://doi.org/10.1080/00207144.2017.1348858
https://doi.org/10.1080/00207144.2017.1348858
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=rcnj20
Contemporary Nurse
ISSN: 1037-6178 (Print) 1839-3535 (Online) Journal homepage: https://www.tandfonline.com/loi/rcnj20
A quasi-experimental study examining a nurse-led
education program to improve knowledge, self-
care, and reduce readmission for individuals with
heart failure
Martha S. Awoke, Diana-Lyn Baptiste, Patricia Davidson, Allen Roberts &
Cheryl Dennison-Himmelfarb
To cite this article: Martha S. Awoke, Diana-Lyn Baptiste, Patricia Davidson, Allen Roberts &
Cheryl Dennison-Himmelfarb (2019) A quasi-experimental study examining a nurse-led education
program to improve knowledge, self-care, and reduce readmission for individuals with heart failure,
Contemporary Nurse, 55:1, 15-26, DOI: 10.1080/10376178.2019.1568198
To link to this article: https://doi.org/10.1080/10376178.2019.1568198
Accepted author version posted online: 11
Jan 2019.
Published online: 28 Jan 2019.
Submit your article to this journal
Article views: 2132
View related articles
View Crossmark data
Citing articles: 3 View citing articles
https://www.tandfonline.com/action/journalInformation?journalCode=rcnj20
https://www.tandfonline.com/loi/rcnj20
https://www.tandfonline.com/action/showCitFormats?doi=10.1080/10376178.2019.1568198
https://doi.org/10.1080/10376178.2019.1568198
https://www.tandfonline.com/action/authorSubmission?journalCode=rcnj20&show=instructions
https://www.tandfonline.com/action/authorSubmission?journalCode=rcnj20&show=instructions
https://www.tandfonline.com/doi/mlt/10.1080/10376178.2019.1568198
https://www.tandfonline.com/doi/mlt/10.1080/10376178.2019.1568198
http://crossmark.crossref.org/dialog/?doi=10.1080/10376178.2019.1568198&domain=pdf&date_stamp=2019-01-11
http://crossmark.crossref.org/dialog/?doi=10.1080/10376178.2019.1568198&domain=pdf&date_stamp=2019-01-11
https://www.tandfonline.com/doi/citedby/10.1080/10376178.2019.1568198#tabModule
https://www.tandfonline.com/doi/citedby/10.1080/10376178.2019.1568198#tabModule
A quasi-experimental study examining a nurse-led education program to
improve knowledge, self-care, and reduce readmission for individuals with
heart failure
Martha S. Awokea**, Diana-Lyn Baptisteb*,**, Patricia Davidsonb, Allen Robertsa and
Cheryl Dennison-Himmelfarbb**
aDepartment of Case Management, Medstar Georgetown University of Hospital, 3800 Reservoir Rd. NW,
Washington, DC 20007, USA; bDepartment of Acute and Chronic Care, Johns Hopkins University School of
Nursing, 525 N. Wolf Street, Baltimore, MD 21205, USA
(Received 21 July 2017; accepted 7 January 2019)
Background: Heart failure affects more than 6 million Americans and an estimated 23 million
people worldwide. Inadequate self-care is associated with readmissions and are identified as a
marker for poor health outcomes. Nurse-led heart failure inpatient hospital education has been
demonstrated to improve knowledge, self-care behaviors and in some studies to reduce 30-day
readmissions.
Aims/Objectives: To evaluate the impact of nurse-led heart failure patient education on
knowledge, self-care behaviors, and all cause 30-day hospital readmission.
Design: Quasi-experimental pre-test and post-test on a convenient sample on two cardiac units
at a large urban facility in the North East region of the United States.
: An evidence-based standardized heart failure patient education program based on the
American Colleges of Cardiology and American Heart Association guidelines was
implemented with a telephone follow-up at 7, 30, and 90 days post-discharge. The duration
of the study was from September 2015 to February 2016. A convenience sample of (N = 29)
individuals diagnosed with heart failure was asked to complete Dutch Heart Failure
Knowledge Scale and Self-care Heart Failure Index.
: A significant difference was found in knowledge at 7 day (P ≤ .001) and 90 day
(P ≤ .032), self-care maintenance at 7 day (P ≤ .000) and 30 day (P ≤ .000), self-care
management at 7 day (P ≤ .001) and 30-day (P≤.013). A statistically significant
difference was found in self-care confidence at 30-day (P ≤ .017) but not at 7 day follow-
up call. A statistically significant improvement in 30-day readmission was not found
(P ≥ .05).
: Findings suggest the importance of developing patient education programs that
are focused on improving knowledge and self-care behaviors for heart failure patients.
Nurses are uniquely qualified to implement such programs that can improve health
outcomes and need to accommodate evidence-based recommendations to global practice
settings.
Keywords: heart failure; patient readmission; knowledge; self-care; nurse-led education;
readmission
© 2019 Informa UK Limited, trading as Taylor & Francis Group
*Corresponding author. Email: dbaptis1@jhu.edu
**These authors contributed equally to this work.
Contemporary Nurse, 2019
Vol. 55, No. 1, 15–26, https://doi.org/10.1080/10376178.2019.1568198
mailto:dbaptis1@jhu.edu
http://www.tandfonline.com
http://crossmark.crossref.org/dialog/?doi=10.1080/10376178.2019.1568198&domain=pdf
It is estimated that 23 million individuals are living with heart failure worldwide (Baptiste
et al., 2016). Approximately 5.8 million Americans have a diagnosis of heart failure and
has reached a national epidemic in the United States (Boisvert et al., 2015; Centers for
Disease Control and Prevention [CDC], 2019; Hart, Spiva, & Kimble, 2011; Sterne, Grossman,
Migliardi, & Swallow, 2014; Wang, Lin, Lee, & Wu, 2011). Heart failure (HF) is the most
common cause of hospital readmission (Sterne et al., 2014). Studies show that nearly 24%
are readmitted within 30 days and 30% of heart failure patients are readmitted within 60–90
days (Askren-Gonzalez & Frater, 2012; Dharmarajan et al., 2013; Paul & Hice, 2014). Further-
more, 27% of Medicare recipients with HF are readmitted within 30-days (Albert, 2012; Hart
et al., 2011; Sterne et al., 2014; Wang et al., 2011; Yancy et al., 2013). The Centers for Med-
icare and Medicaid Services (CMS) defines readmission as an unplanned re-hospitalization for
any cause to an acute care hospital within 30 days of discharge (Baptiste et al., 2016; Dennison
et al., 2011). Frequent readmission is a financial burden on patients, their families, and health
care systems (Toback & Clark, 2017). The cost of treating heart failure, including lost wages
and lost productivity in the United States is estimated at $32 billion per year (CDC, 2019; Hart
et al., 2011; Paul & Hice, 2014; Yancy et al., 2017).
Hospital readmissions are associated with poor health outcomes. Dharmarajan et al. (2013)
reported that readmission within 30-days is the most vulnerable period for individuals with
heart failure. Hospital readmissions are commonly attributed to factors such as, individuals’
lack of knowledge about disease processes, inadequate symptom recognition, and inability to
make prompt and appropriate decisions to manage symptoms, and the absence of timely
follow-up with a health care provider (Askren-Gonzalez & Frater, 2012; Dennison et al., 2011;
Dracup et al., 2012; Spaling, Currie, Strachan, Harkness, & Clark, 2015; Paul & Hice, 2014).
For patients with heart failure, the level of knowledge about disease process is positively corre-
lated with the ability to recognize and manage symptoms as they arise, therefore initial assessment
of patient’s knowledge and self-care behaviors by nurses prior to engaging in patient education is
essential to provide an appropriate patient education (Albert, 2012; Riegel et al., 2009).
Nurse-led heart failure inpatient hospital education has been demonstrated to improve knowl-
edge, self-care behaviors and in some studies to reduce 30-day readmissions (Albert, 2012; Dom-
ingues, Clausell, Aliti, Dominguez, & Rabelo, 2011; Kommuri, Johnson, & Koelling, 2012; Paul
& Hice, 2014; Yancy et al., 2013). In 2017, the American Colleges of Cardiology Foundation
(ACCF) and American Heart Association (AHA) updated the 2013 practice guidelines for the
management of heart failure, focused on most effective strategies for improving the quality of
care, resources, and patient outcomes (Yancy et al., 2013). ACCF/AHA best practice guidelines
recommend a one-to-one nurse-led HF education encompassing diet, activity, weight monitoring,
smoking cessation, fluid restriction, medication adherence, keeping follow-up appointments and a
reduction in hospitalizations. (Albert, 2012; Sterne et al., 2014; Yancy et al., 2013; Yancy et al.,
2017). The ACCF/AHA guidelines recommend one-on-one nurse-led education by specialist
nurses who can promote adherence to treatments and healthy lifestyles for individuals with
heart failure. Improving knowledge about signs and symptoms of disease progression, treatment
plan, and actions to engage in to manage symptoms has been reported to minimize exacerbation
and frequent hospitalization (Suk Lee et al., 2015; van der Wal, Jaarsma, Moser, & van Veldhui-
sen, 2005). The purpose of this study was to implement a standardized nurse-led heart failure edu-
cation program focused on improving knowledge and self-care behaviors for individuals living
with heart failure.
16 M.S. Awoke et al.
Methods
Design, setting, participants
A quasi-experimental study, using pre-test and post-test implemented on a convenient sample on
two cardiac units at a large urban facility in the North East region. The principal investigator
(PI) screened charts for a primary and/or secondary diagnosis of heart failure and eligibility. The
PI then approached eligible patients to obtain verbal consent for participation. The inclusion criteria
for eligibility were: (1) All heart failure patients admitted to the two cardiac units, (2) patients dis-
charge destination is to home, (3) patients are able to give written or verbal consent for themselves,
(4) patients equal to and older than 18 years old, and (5) patient who speak English. Exclusion cri-
teria were: (1) patients younger than 18 years old, (2) non-English speaking, (3) patients unable to
provide informed consent, (4) patients not discharged to home, and (5) patients not admitted to the
two cardiovascular units. Eligible patients who agreed to participate were given a baseline knowl-
edge and self-care behavior assessment using validated tools: Dutch Heart Failure Knowledge
Scale and Self-care Heart Failure Index. Then participants were engaged in a one-on-one nurse-
led heart failure education by the PI and reinforced by the unit nurses. Participants were provided
with a visual color-coded (Green, Yellow, and Red) guide to monitor symptoms and actions they
should take based on the symptom that corresponded with the color (Figure 1).
The evidence-based standardized heart failure patient education program was implemented
with telephone follow-up at 7, 30, and 90 days post-discharge. Individuals (N = 29) diagnosed
with heart failure were asked to complete Dutch Heart Failure Knowledge Scale (DHFKS) and
Self-care Heart Failure Index (SCHFI) prior to hospital discharge. The DHFKS scores were eval-
uated during the pre-intervention period, then at 7 and 90 days after hospital discharge. SCHFI
questionnaires were distributed to participants at the pre-intervention time period, with a
follow-up at 7 and 30 days after hospital discharge. Staff nurses of both cardiac units were
asked to complete a Conviction and Confidence scale prior to initiating patient education
(Agency for Healthcare Research and Quality, 2015; Xu, 2012). Power analysis for a dependent
sample t-test was conducted to determine a sufficient sample size using an alpha of 0.05, a power
of 0.80 (Liou et al., 2015; Sterne et al., 2014). Based on the previous studies conducted by Liou
Figure 1. Study diagram.
Contemporary Nurse 17
et al. (2015), and Dennison et al. (2011) the desired sample size to produce a change in scores for
DHFKS was N = 6, and SCHFI was N = 16.
Prior to patient education, nurses on the two cardiac units were provided with a one-hour
training during a lunch and learn sessions for three consecutive days on each clinical unit. Edu-
cation sessions for the nurses were carried out across six days. To promote understanding and con-
sistency, nurses were asked to recapitulate the content in their own words and use the Robert
Woods Johnson Foundation’s (RWJF) Living with Heart Failure: A patient Teaching Guide.
Content for the RWJF standardized heart failure patient education materials are based on the
ACCF/AHA guidelines addressing diet, activity, weight monitoring, smoking cessation, fluid
restriction, medication adherence, and keeping follow-up appointments (Robert Woods
Johnson Foundation, 2011). Participants were then engaged in a one-to-one nurse-led heart
failure education by the PI and received daily follow-up education sessions with staff nurses.
Nurses provided two, one-to-one education sessions to participants during hospitalization over
30 minutes, using the RWJF standardized heart failure instructional materials. The education
program was implemented with a telephone follow-up at 7, 30, and 90 days post-discharge.
The duration of the study was from September 2015 to February 2016. Participants were provided
with a visual color coded (Green, Yellow, and Red) self-care guide to monitor symptoms and
actions they should take based on the symptom that corresponded with the color (Figure 2).
Participants were contacted via telephone by the PI at 7 days, 30-days and 90-days after hos-
pital discharge. During the follow-up period, participants were asked to complete the SCHFI and
DHFKS questionnaires at different points in time. A follow-up call was made at 7 and 30-days
after hospitalization to complete SCHFI, and at 7 and 90-days to complete DHFKS questionnaire.
In addition, participants were evaluated for readmission, 30-days after hospital discharge.
In this study the PI identified three outcomes. The primary outcome was to improve knowl-
edge and measure it using a validated and reliable instrument, the Dutch Heart Failure Index (van
der Wal, et al., 2005). The second outcome was to improve self-care maintenance, self-care man-
agement, and self-care confidence using a validated and reliable instrument, Self-Care Heart
Failure Index (Barbaranelli, Lee, Vellone, & Riegel, 2014; Riegel et al., 2009). The Dutch
Heart Failure Knowledge scale (DHFKS) is a 15-item instrument that measures the individual’s
general knowledge about heart failure (van der Wal et al., 2005). The Self-care Heart Failure
Index (SCHFI) is a 22-item instrument that measures self-care behaviors using three sub-
scales: self-care maintenance, self-care management, and self-care confidence (Barbaranelli
et al., 2014). The third outcome was to reduce 30-day all cause readmissions. The investigators
also examined the nurses’ ease of using teach-back method during patient education with the Con-
fidence and Conviction Scale tool (Xu, 2012). The Confidence and Conviction scale is a 4-item
instrument that evaluates beliefs about the importance of using teach-back method and confidence
during patient education. Teach-back method, also known as ‘show me’, provides insight into the
level of patient’s understanding of the instruction provided by the health care provider by prompt-
ing the patient to reiterate what they have learned in their own words (Dinh, Bonner, Clark, Rams-
botham, & Hines, 2016). This method is frequently used in clinical settings when providing
patient education. The main goal of teach-back is to have the learner demonstrate their knowledge
by repeating back what they are taught (Dinh et al., 2016).
Theoretical framework
Caring for individuals with heart failure is unique and challenging. The study was conducted at
the large urban teaching hospital where the population served came from a diverse cultural, socio-
economic, and educational backgrounds. This study drew on the Theory of Culture Care &
18 M.S. Awoke et al.
Transcultural Nursing developed by Madeline Leininger to promote individualized patient edu-
cation that is unique to the patient’s own experience and knowledge (Leininger, 1988).
The theory of Culture Care & Transcultural nursing defines culture as ‘learned, shared, and
transmitted values, beliefs, norms of a group that influences behavior’ (Leininger, 1988). As
such, intervention planned considered the patient’s cultural background, beliefs and values to
encourage active patient engagement and adaptation. Additionally, the delivery method of
patient education and patient’s response was continuously evaluated to increase patient engage-
ment and promote adherence to treatment plan.
Figure 2. Patient symptom monitoring guide. Source: UCONN Health Center.
Contemporary Nurse 19
The study was approved by the organization’s Institutional Review Board and deemed as quality
improvement. Expedited approval was granted.
Instruments
Conviction and Confidence Scale
Nurses on the designated units were asked to complete an initial Conviction and Confidence
Scale. A Conviction and Confidence Scale measures the nurse’s belief and confidence level
when using teach-back method during patient education. Teach-back method is an educational
technique that actively engages patients during nurse education by prompting patients to reiterate
their understanding (Agency for Healthcare Research and Quality, 2015; Xu, 2012). Using teach-
back method ensures that patients are engaged and assume ownership of their own health (Agency
for Healthcare Research and Quality, 2015).
Dutch Heart Failure Knowledge Scale
Patient’s heart failure knowledge was measured using Dutch Heart Failure Knowledge Scale
(DHFKS). DHFKS is a 15-item multiple choice questionnaire. The DHFKS consists of four ques-
tions assessing general knowledge, six questions on diet, fluid restriction and activity, and five
questions assessing knowledge regarding symptoms and symptom recognition. Reliability and
construct validity was determined by the author, reporting a Cronbach α .62. The scale has a
minimum score of 0 and a maximum score of 15 points (van der Wal et al., 2005).
Self-care Heart Failure Index
Self-care behavior was measured using the SCHFI V.6.2, developed by Riegel and colleagues
(2009) specifically for use with individuals with heart failure. SCHFI is a 22-item questionnaire
that is divided into 3 subscales: self-care maintenance, self-care management, and self-care con-
fidence. Self-care maintenance measures patient’s ability to maintain health by adhering to treat-
ment advice and performing tasks such as daily weight, medication adherence and following a
low salt diet. Self-care maintenance consists of 10 questions with a minimum score of 10 and
maximum score of 40 (Barbaranelli et al., 2014).
Self-care management measures patients’ ability to recognize symptoms and perform tasks to
manage symptoms as they arise. Self-care management has a minimum score of 4 and maximum
score of 24. Self-care confidence measures, patients perceived confidence in recognizing and
managing symptoms to maintain health. Self-care confidence has a minimum score of 6 and
maximum of 24. Each of the scales use a 4-point Likert scale, self-report reply format: 1(never
or rarely), 2 (sometimes), 3 (frequently), 4 (always or daily). A standardized score of 0–100
for each of the sub-scale is used for better interpretation. A score of 70 or greater in each subscale
is thought to reflect good self-care behavior. The reliability of the subscales as reported by Riegel
is as follows: Self-care maintenance 0.56, self-care management 0.70, and self-care confidence
0.80 (Riegel et al., 2009; Barbaranelli et al., 2014).
Data analysis was conducted using SPSS® 24 (IBM Corporation, Armonk, NY, USA). Descrip-
tive statistics were analyzed the characteristics of the demographic for the sample. Frequency
20 M.S. Awoke et al.
statistics were analyzed to identify the characteristics of nurse’s response to the Conviction and
Confidence scale. A paired t-test was completed to compare baseline knowledge and self-care
scores with the follow-up period at 7, 30, and 90-days post hospitalization. A p-value <.05 is con-
sidered statistically significant. A Chi-square test was completed to analyze a change in 30-day
readmission during the study period, from September 2016 through February 2017 compared
to the same time period the year before.
Results
Demographics
Descriptive statistics were used to evaluate frequencies among the N = 29 participants (Table 1).
Demographic characteristics were collected from medical records and participant interviews. The
sample consisted of n = 15 (52%) men and n = 14 (48%) women admitted to one of the two
cardiac inpatient units, with the primary and secondary diagnosis of heart failure. The majority
of patients within this sample had a New York Heart Association Classification (NYHA)
scores of III-IV (69%), with more that 62% having an ejection fraction of less than 55%. The
mean age of participants was 66, ranging from 47 to 90 years of age, with 75% of this group
being not married, widowed, or divorced. Sixty-two percent (n = 18) of participants identified
as African American and n = 10 (34%) Caucasian, with one patient reportedly Hispanic. Of the
N = 29 participants, n = 10 were either lost to follow or requested to be removed from the study.
Nurses Conviction and Confidence Score
A sample size of N = 23 nurses completed the Confidence and Conviction Scale. Of that one nurse
did not complete the educational level and years of experience. From N = 22, 81% of nurses (n =
Table 1. Demographic characteristics.
Mean ± SD
n = 29
Age 66 ± 11.5
Gender
Males 15 ± 51.7
Females 14 ± 48.3
Race
Caucasian 10 ± 34.5
African-American 18 ± 62.1
Hispanic 1 ± 3.4
Marital Status
Married 7 ± 24.1
Not-married (single, divorced, widowed) 22 ± 75.9
Work
Employed 11 ± 37.9
Unemployed, retired, disability 18 ± 62.1
NYHA
Class I 5 ± 17.2
Class II 4 ± 13.8
Class III 8 ± 27.6
Class IV 12 ± 41.4
Ejection Fraction
=55% 11 ± 37.9
<55% 18 ± 62.1
Contemporary Nurse 21
18) had a baccalaureate degree and 59% (n = 13) had 1–3 years of experience. Overall, the nurses
were convinced that using teach-back method was very important, mean 9.39 ± 0.89, and the
nurses reported being confident at using teach back method with mean 7.52 ± 1.78. Approxi-
mately 69% of the nurses reported using teach-back method during patient education. Nurses’
response to their belief and conviction about using Teach-back method and the length of time
they have been using Teach-back method.
Dutch Heart Failure Knowledge Score
The DHFKS was used to evaluate individual knowledge among participants at two points in time
evaluating baseline scores from baseline to 7 days and baseline to 90 days. Baseline knowledge
scores yielded a statistically significant increase by 1.38 points (p = .001) at the 7-day follow-up
period. Similar to previous studies, participants in this study had a mean baseline knowledge score
of 11.96, out of 15 being the highest achievable score (Dennison et al., 2011; van der Wal et al.,
2005). Knowledge scores at the 90-day follow-up period significantly increased and remained
higher than baseline knowledge scores by two points (11.96 vs. 13.31; p = .032) respectively
(Table 2). Based on these results, we can infer that nurse-led heart failure education positively
impacts patients’ knowledge level about the disease process.
Self-care Heart Failure Index Score
Self-care maintenance scores significantly increased from a mean of 64.59to 85.43 (p = .000) and
self-care management scores increased from 55.86to 78.68 (p = .001) at the 7-day follow-up
period. In this study the participants had adequate self-care confidence scores at baseline
(>70), but there was no significant difference at the 7-day follow-up in the self-care confidence
scores (p = .204). There was a statistically significant difference in self-care confidence
between at the baseline and 30-day follow-up (p = .017). In addition, mean self-care maintenance
and self-care management scores were greater than 70 (Table 3).
Table 2. Dutch heart failure knowledge scores.
DHFKS
Total sample
N = 29
T0 (Baseline)
n = 19
T1 (7 days)
n = 16
T3 (90 days) T1 to T2 P T1 to T3 P
DHFKS, mean (SD) 11.965 (1.76) 13.32 (2.08) 13.31 (1.29) .001** .032**
Note: P-value < .05 is considered statistically significant. **Statistically significant.
Table 3. Mean self-care Heart Failure Index scores.
Mean SCHFI Scores
T0 (Baseline)
N = 29
T1 (7-days)
N = 19
T2 (30-days)
N = 18 T0 to T1 P T0 to T2 P
SCHFI Maintenance, Mean
(SD)
64.59 (17.76) 85.43 (10.32) 89.07 (8.39) .000** .000**
SCHFI Management, Mean
(SD)
55.86 (15.64) 78.68 (17.15) 76.50 (17.01) .001** .013**
SCHFI Confidence, Mean (SD) 71.61 (16.62) 77.84 (17.48) 86.18 (14.18) .169 .017**
Note: A P value <.05 is considered statistically significant. **Statistically significant.
22 M.S. Awoke et al.
30-day readmission
Overall the readmission rate for all-cause for this group (n = 5) did not change in comparison to
the group from the prior year (n = 12) at 17%. There was no significant difference in the readmis-
sion rates between the two samples.
Heart failure is a common condition with a high symptom burden (Albert, 2012). Some of the
challenges reported by participants in this study were related to maintaining fluid restrictions;
engaging in daily physical activity; and difficulty obtaining a follow-up appointment within
the recommended time. As described in the demographic data (Table 1), 41% of the participants
had a Class IV NYHA and 62% had an EF ≤ 55% which may have precluded the individuals from
engaging in activity and adhering to their appointments as scheduled. Additionally, other co-mor-
bidities that required adequate hydration were competing factors that challenged patients about
adhering to fluid restriction. Participants in this study reported adhering to medications and avoid-
ing salty food. However, the attrition rate (n = 10) for this study was high (33%) compared to the
acceptable rate of about 20% (Amico, 2009). The attrition rate is attributed to death; readmissions
for a significant event and a change in discharge destination to a nursing home; participants
requesting to be removed from the study; and participants lost to follow-up. Previous study
had suggested that a telephone follow-up within 7-days after discharge may improve participation
(Baptiste et al., 2016), however, in this study, participants lost to follow-up were observed during
the initial follow-up period. Individuals with advanced heart failure may not be able to participate
due to fatigue and disease burden (Boisvert et al., 2015). A comparison analysis of the NYHA
classification between the participants who completed the study and the attrition rate found
that majority of the participants in the attrition group had NYHA class IV classification.
Further study is warranted to uncover methods to engage the sicker heart failure patients in
self-care behavior.
The population in this study demonstrated an improved knowledge and self-care confidence
scores. This is similar to the previous study reported by Liou et al. (2015). At the follow-up
period, the study population demonstrated an improvement in knowledge, self-care maintenance,
self-care management, and self-care confidence scores. However, the 30-day readmission rate was
not statistically significant when compared to the same time period the previous year. This may be
due to the small sample size. Further study is warranted on large sample size to see the effect of
knowledge and self-care behavior on readmission.
Nurses are in a unique position to influence health behavior by engaging patients during hos-
pitalization (Albert, 2012). Nurses have to feel comfortable and prepared to educate patients.
Examination of the nurses’ belief and confidence to use teach-back method revealed that the
majority of the nurses (70%) reported being comfortable using open-ended questions and enga-
ging patients during health education using teach-back method. Moreover, close to 70% of the
nurses reported to using teach-back method and another 22% of the nurses planned to use
teach-back method in the next month. Most nurses n = 23 (mean 9.39 ± 0.89) responded that
they were convinced that using teach-back method is important.
There were several limitations in this study. First, this was a non-randomized sample without a
control group. Second, it was a convenience sample from two cardiovascular units at a single
site. Third, the study is not generalizable due to the small size of the participants. Finally, the
study was short in duration, and possibly limited the number of participants.
Contemporary Nurse 23
This study showed that individualized one-on-one nurse-led heart failure education improved
patient’s knowledge and self-care maintenance, management, and confidence. It is rec-
ommended that hospitals implement a nurse-led heart failure education that encompasses the
key factors identified by expert opinions (Yancy et al., 2013). In addition it is recommended
that a timely follow-up schedule should be provided to the patient prior to discharge to ease
the burden on patients as they are adjusting to their daily routine. Additionally, nurses are
encouraged to use evidence-based teaching methods to enhance the patient’s comprehension
of presented education.
Nurse-led heart failure education can improve knowledge, self-care, and reduce readmissions for
individuals with heart failure. Nurses are uniquely qualified to implement such programs that can
improve health outcomes and need to accommodate evidence-based recommendations to practice
settings across the globe.
Conclusion
It is essential that nurses must feel prepared and knowledgeable on methods to actively engage
patients during health education, because, improving knowledge and self-care behavior has
demonstrated patient’s ability to care for self by taking appropriate actions to minimize disease
exacerbation.
Health care providers can alleviate some of the barriers by scheduling follow-up appointments
prior to patient’s discharge, by discussing how to balance restrictions necessary to maintain free of
fluid overload with other co-morbidities that require adequate fluid intake, and by encouraging
patients to gradually increase activity level. Challenges incurred during this study were related
to the sample size. Nurse researchers can translate findings from this study to clinical practice.
The investigation is necessary to explore cost-effective ways to provide education interventions
that would improve self-care, knowledge, and minimize readmissions (Toback & Clark, 2017).
Further study is needed to look at the effect of improving knowledge and self-care behavior on
30-day readmission.
We would like to thank the following groups: (1) Dr Lisa Boyle Chief Medical Officer at Medstar George-
town University Hospital; the Case Management Department Alma Ray RN, Pat Murley RN, Ruth Adonizio
RN, Edith Simmons at Medstar Georgetown University Hospital; Nursing staff and patients at Medstar Geor-
getown University Hospital; Quality Improvement Department Hanan Foley RN, Elizabeth Freedman MPH
at Medstar Georgetown University Hospital; (2).Dr Laura Samuel, Dr Leah Jager, Ms. Denise Rucker, Dr
Deborah Finnell, Dr Nancy Goldstein, and Dr Deborah Baker at the Johns Hopkins School of Nursing;
(3) and Dr van der Wal, who provided guidance with scoring for the Dutch Heart Failure Knowledge
Scale. MA served as the PI, carried out the study, participated in the conception, design, and coordination,
acquisition of data, interpretation of data, performed statistical analysis, drafted and revised the manuscript.
AR helped in the study implementation period and provided logistical guidance. PMD provided writing
assistance, critically revised the manuscript for important intellectual content. DB participated in the
design, coordination, and interpretation of data, statistical analysis of data, and helped draft and revised
the manuscript. CDH participated in the design, coordination, and interpretation of data, and helped draft
and revised manuscript.
24 M.S. Awoke et al.
Agency for Healthcare Research and Quality. (2015). Use the Teach-Back Method. Retrieved from https://
www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacytoolkit/
healthlittoolkit2-tool5.html
Albert, N. M. (2012). Fluid management strategies in heart failure. Critical Care Nurse, 32(2), 20–33.
doi:10.4037/ccn2012877
Amico, K. R. (2009). Percent Total attrition: A poor metric for study rigor in hosted intervention designs.
American Journal of Public Health, 99(9), 1567–1575. doi:10.2105/AJPH.2008.134767
Askren-Gonzalez, A., & Frater, J. (2012). Case management programs for hospital readmission prevention.
Professional Case Management, 17(5), 219–226. doi:10.1097/NCM.0b013e318257347d
Baptiste, D. L., Davidson, P., Groff Paris, L., Becker, K., Magloire, T., & Taylor, L. A. (2016). Feasibility
study of a nurse-led heart failure education program. Contemporary Nurse, 52(4), 499–510.
Barbaranelli, C., Lee, C. S., Vellone, E., & Riegel, B. (2014). Dimensionality and reliability of the self-care
of heart failure index scales: Further evidence from confirmatory factor analysis. Research in Nursing &
Health, 37(6), 524–537. doi:10.1002/nur.21623
Boisvert, S., Proulx-Belhumeur, A., Doré, M., Gonçalves, N., Francoeur, J., & Gallani, M. C. (2015). An
integrative literature review on nursing interventions aimed at increasing self-care among heart failure
patients. Revista Latino-Americana De Enfermagem (RLAE), 23(4), 753–768. doi:10.1590/0104-
1169.0370.2612
Centers for Disease Control and Prevention. (2019). Heart failure fact sheet. Retrieved from http://www.cdc.
gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm
Copyright. (2011). Robert Wood Johnson Foundation. Used with permission from the Robert Wood Johnson
Foundation.
Dennison, R. C., McEntee, L. M., Samuel, L., Johnson, J. B., Rotman, S., Kielty, A., & Russell, D. S. (2011).
Adequate health literacy is associated with higher heart failure knowledge and self-care confidence in
hospitalized patients. Journal of Cardiovascular Nursing, 26(5), 359–367. doi:10.1097/JCN.
0b013e3181f16f88
Dharmarajan, K., Hsieh, A.F. , Lin, Z., Bueno, H., Ross, J.S., Horowitz, L.I., … Krumholz, H.M. (2013).
Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute
Myocardial Infarction, or Pneumonia. JAMA, 4(309), 355–363. doi:10.1001/jama.2012.216476
Dinh, T. T. H., Bonner, A., Clark, R., Ramsbotham, J., & Hines, S. (2016). The effectiveness of the teach-
back method on adherence and self-management in health education for people with chronic disease: A
systematic review. JBI Database of Systematic Reviews and Implementation Reports, 14(1), 210–247.
Domingues, F. B., Clausell, N., Aliti, G. B., Dominguez, D. R., & Rabelo, E. R. (2011). Education and tele-
phone monitoring by nurses of patients with heart failure: Randomized clinical trial. Arquivos
Brasileiros De Cardiologia JID – 0421031, (0066-782). doi:10.1590/S0066-782X2011005000014
Dracup, K., Moser, D. K., Pelter, M. M., Nesbitt, T., Southard, J., Robinson, S., … Cooper, L. (2012).
Improving self care behavior and clinical outcomes in rural patients with heart failure. Journal of
Cardiac Failure, 18(11), 882–883.
Hart, P. L., Spiva, L., & Kimble, L. P. (2011). Nurses’ knowledge of heart failure education principles survey:
A psychometric study. Journal of Clinical Nursing, 20(21), 3020–3028. doi:10.1111/j.1365-2702.2011.
03717.xii]
Kommuri, N. V., Johnson, M. L., & Koelling, T. M. (2012). Relationship between improvements in heart
failure patient disease specific knowledge and clinical events as part of a randomized controlled trial.
Patient Education and Counseling, 86(2), 233–238. doi:10.1016/j.pec.2011.05.019
Lee, K. S., Lennie, T. A., Dunbar, S. B., Pressler, S. J., Heo, S., Song, E. K., … Moser, D. K. (2015). The
association between regular symptom monitoring and self-care management in patients with heart
failure. The Journal of cardiovascular nursing, 30(2), 145.
Leininger, M. M. (1988). Leininger’s theory of nursing: Cultural care diversity and universality. Nursing
Science Quarterly, 1(4), 152–160. doi:10.1177/089431848800100408
Liou, H. L., Chen, H. I., Hsu, S. C., Lee, S. C., Chang, C. J., & Wu, M. J. (2015). The effects of a self-care
program on patients with heart failure. Journal of the Chinese Medical Association: JCMA, 78(11), 648–
656. doi:S172-4901(15)00149-5
Paul, S., & Hice, A. (2014). Role of the acute care nurse in managing patients with heart failure using evi-
dence-based care. Critical Care Nursing Quarterly, 37(4), 357–376.
Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., … Peterson, P. N. (2009).
State of the science: Promoting self-care in persons with heart failure: A scientific statement from the
American Heart Association. Circulation, 120(12), 1141–1163.
Contemporary Nurse 25
https://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacytoolkit/healthlittoolkit2-tool5.html
https://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacytoolkit/healthlittoolkit2-tool5.html
https://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacytoolkit/healthlittoolkit2-tool5.html
https://doi.org/10.4037/ccn2012877
https://doi.org/10.2105/AJPH.2008.134767
https://doi.org/10.1097/NCM.0b013e318257347d
https://doi.org/10.1002/nur.21623
https://doi.org/10.1590/0104-1169.0370.2612
https://doi.org/10.1590/0104-1169.0370.2612
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm
https://doi.org/10.1097/JCN.0b013e3181f16f88
https://doi.org/10.1097/JCN.0b013e3181f16f88
https://doi.org/10.1001/jama.2012.216476
https://doi.org/10.1590/S0066-782X2011005000014
https://doi.org/10.1111/j.1365-2702.2011.03717.xii]
https://doi.org/10.1111/j.1365-2702.2011.03717.xii]
https://doi.org/10.1016/j.pec.2011.05.019
https://doi.org/10.1177/089431848800100408
doi:S172-4901(15)00149-5
Spaling, M. A., Currie, K., Strachan, P. H., Harkness, K., & Clark, A. M. (2015). Improving support for heart
failure patients: A systematic review to understand patients’ perspectives on self-care. Journal of
Advanced Nursing, 71(11), 2478–2489. doi:10.1111/jan.12712
Sterne, P. P., Grossman, S., Migliardi, J. S., & Swallow, A. D. (2014). Nurses’ knowledge of heart failure:
Implications for decreasing 30-day re-admission rates. MEDSURG Nursing, 23(5), 321–329.
Toback, M., & Clark, N. (2017). Strategies to improve self-management in heart failure patients.
Contemporary Nurse, 53(1), 105–120.
van der Wal, M. H., Jaarsma, T., Moser, D. K., & van Veldhuisen, D. J. (2005). Development and testing of
the Dutch heart failure knowledge scale. European Journal of Cardiovascular Nursing, 4(4), 273–277.
Wang, S., Lin, L., Lee, C., & Wu, S. (2011). Effectiveness of a self-care program in improving symptom
distress and quality of life in congestive heart failure patients: A preliminary study. Journal of
Nursing Research (Lippincott Williams & Wilkins, 19(4), 257–266.
Xu, P. (2012). Using teach-back for patient education and self-management. American Nurse Today, 7(3), 2.
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., … Hollenberg, S. M. (2017).
2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart
failure: A report of the American College of Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines and the Heart Failure Society of America. Journal of the American
College of Cardiology, 70(6), 776–803.
Yancy, C. W, Jessup, M, Bozkurt, B, Butler, J, Casey, D. E., Jr, & Drazner, M. H., … American Heart
Association Task Force on Practice Guidelines. (2013). 2013 ACCF/AHA guideline for the management
of heart failure: A report of the American College of Cardiology Foundation/American heart association
task force on practice guidelines. Journal of the American College of Cardiology, 62(16), e147-e239.
doi:10.1016/j.jacc.2013.05.019
26 M.S. Awoke et al.
https://doi.org/10.1111/jan.12712
https://doi.org/10.1016/j.jacc.2013.05.019
- Abstract
Introduction
Methods
Design, setting, participants
Theoretical framework
Ethical considerations
Data collection
Instruments
Conviction and Confidence Scale
Dutch Heart Failure Knowledge Scale
Self-care Heart Failure Index
Analysis
Results
Demographics
Nurses Conviction and Confidence Score
Dutch Heart Failure Knowledge Score
Self-care Heart Failure Index Score
30-day readmission
Discussion
Limitations
Implication for practice
Impact statement
Conclusion
Acknowledgements
References