Harleah G. Buck

Spirituality: Concept Analysis and Model Development

The concept of spirituality has gained increasing attention over the last decade, as evidenced by the number of conceptual and empirical articles published. Many recommend that continued theory development is essential to understand spirituality and guide practice. The aim of this article is to review the nursing research on spirituality and conduct a concept analysis using Chinn and Kramers method of creating conceptual meaning. A definition of spirituality is presented, and a model constructed from a review of the literature and reflection. Spirituality is defined as: that most human of experiences that seeks to transcend self and find meaning and purpose through connection with others, nature, and/or a Supreme Being, which may or may not involve religious structures or traditions.

Caregivers’ contributions to heart failure self-care: A systematic review:

Aims: The purpose of this study was to conduct a systematic review answering the following questions: (a) what specific activities do caregivers (CGs) contribute to patients’ self-care in heart failure (HF)?; and (b) how mature (or developed) is the science of the CG contribution to self-care? Methods: MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library and ClinicalTrials.gov were searched using the terms heart failure and caregiv* as well as the keywords ‘careers’, ‘family members’ and ‘lay persons’ for studies published between 1948 and September 2012. Inclusion criteria for studies were: informal CGs of adult HF patients–either as dependent/independent variable in quantitative studies or participant in qualitative studies; English language. Exclusion criteria for studies were: formal CGs; pediatric, adult congenital, or devices or transplant CGs; mixed diagnosis; non-empiric reports or reports publishing duplicate results. Each study was abstracted and confirmed by two authors. After CG activities were identified and theoretically categorized, an analysis across studies was conducted. Results: Forty papers were reviewed from a pool of 283 papers. CGs contribute substantively to HF patients’ self-care characterized from concrete (weighing the patient) to interpersonal (providing understanding). Only two studies attempted to quantify the impact of CGs’ activities on patients’ self-care reporting a positive impact. Our analysis provides evidence for a rapidly developing science that is based largely on observational research. Conclusions and implications of key findings: To our knowledge, this is the first systematic review to examine CGs’ contributions in depth. Informal caregivers play a major role in HF self-care. Longitudinal research is needed to examine the impact of CGs’ contributions on patient self-care outcomes.

Multiple Comorbid Conditions Challenge Heart Failure Self-Care by Decreasing Self-Efficacy

Background:Most heart failure patients have multiple comorbidities. Objective:This study aims to test the moderating effect of comorbidity on the relationship between self-efficacy and self-care in adults with heart failure. Methods:Secondary analysis of four mixed methods studies (n = 114) was done. Self-care and self-efficacy were measured using the Self-Care of Heart Failure Index. Comorbidity was measured with the Charlson Comorbidity Index. Parametric statistics were used to examine the relationships among self-efficacy, self-care, and the moderating influence of comorbidity. Qualitative data yielded themes about self-efficacy in self-care and explained the influence of comorbidity on self-care. Results:Most (79%) reported two or more comorbidities. There was a significant relationship between self-care and the number of comorbidities (r = −.25; p = .03). There were significant differences in self-care by comorbidity level (self-care maintenance, F[1, 112], 5.96, p = .019, and self-care management, F[1, 72], 4.66, p = .034). Using moderator analysis of the effect of comorbidity on self-efficacy and self-care, a significant effect was found only in self-care maintenance among those who had moderate levels of comorbidity (b = .620, p = .022, Fchange df[6,48], 5.61, p = .022). In the qualitative data, self-efficacy emerged as an important variable influencing self-care by shaping how individuals prioritized and integrated multiple and often competing self-care instructions. Discussion:Comorbidity influences the relationship between self-efficacy and self-care maintenance, but only when levels of comorbidity are moderately high. Methods of improving self-efficacy may improve self-care in those with multiple comorbidities.

Relationship between self-care and health-related quality of life in older adults with moderate to advanced heart failure.

Background:Heart failure (HF) patients who follow the treatment regimen and attend to symptoms before they escalate are assumed to have better health-related quality of life (HRQOL) than those with poor self-care, but there are few data available to support or refute this assumption. Objective:The objective of the study was to describe the relationship between HF self-care and HRQOL in older (≥65 years old) adults with moderate to advanced HF. Methods:Self-care was measured using the 3 scales (maintenance, management, and confidence) of the Self-care of Heart Failure Index. Scores range from 0 to 100, with higher numbers indicating better self-care. Health-related quality of life was measured with the Minnesota Living With Heart Failure Questionnaire, a 2-subscale (physical and emotional) instrument. Lower numbers on the Minnesota Living With Heart Failure Questionnaire indicate better HRQOL. Pearson correlations, independent-samples t-tests, and linear and logistic regression modeling were used in the analysis. Results:In 207 adults (72.9 [SD, 6.3] years), New York Heart Association class III (82%) or IV, significant linear associations were observed between self-care confidence and total (r = −0.211; P = .002), physical (r = −0.189; P = .006), and emotional HRQOL (r = −0.201; P = .004). Patients reporting better (below median) HRQOL had higher confidence scores compared with patients reporting above-median HRQOL scores (58.8 [19.2] vs 52.8 [19.6]; P = .028). Confidence was an independent determinant of total (&bgr;s = −3.191; P = .002), physical (&bgr;s = −2.346; P = .002), and emotional (&bgr;s = −3.182; P = .002) HRQOL controlling for other Self-care of Heart Failure Index scores, age, gender, and New York Heart Association class. Each 1-point increase in confidence was associated with a decrease in the likelihood that patients had worse (above median) HRQOL scores (odds ratio, 0.980 [95% confidence interval, 0.963–0.998]) with the same controls. No significant associations were found between self-care maintenance or management and HRQOL. Conclusions:The degree of individual confidence in HF self-care is related to HRQOL, but self-reports of specific maintenance and management behaviors are not. Interventions that improve self-care confidence may be particularly important in older adults with moderate to advanced HF.

Patterns and predictors of patient and caregiver engagement in heart failure care: A multi-level dyadic study

BACKGROUND Heart failure is a burdensome clinical syndrome, and patients and their caregivers are responsible for the vast majority of heart failure care. OBJECTIVES This study aimed to characterize naturally occurring archetypes of patient-caregiver dyads with respect to patient and caregiver contributions to heart failure self-care, and to identify patient-, caregiver- and dyadic-level determinants thereof. DESIGN Dyadic analysis of cross-sectional data on patients and their caregivers. SETTING Outpatient heart failure clinics in 28 Italian provinces. PARTICIPANTS 509 Italian heart failure patients and their primary caregivers. METHODS Multilevel and mixture modeling were used to generate dyadic averages and incongruence in patient and caregiver contributions to heart failure self-care and identify common dyadic archetypes, respectively. RESULTS Three distinct archetypes were observed. 22.4% of dyads were labeled as novice and complementary because patients and caregivers contributed to different aspects of heart failure self-care that was generally poor; these dyads were predominantly older adults with less severe heart failure and their adult child caregivers. 56.4% of dyads were labeled as inconsistent and compensatory because caregivers reported greater contributions to the areas of self-care most insufficient on the part of the patients; patients in these dyads had the highest prevalence of hospitalizations for heart failure in the past year and the fewest limitations to performing activities of daily living independently. Finally, 21.2% of dyads were labeled as expert and collaborative because of high contributions to all aspects of heart failure self-care, the best relationship quality and lowest caregiver strain compared with the other archetypes; patients in this archetype were likely the sickest because they also had the worst heart failure-related quality of life. CONCLUSION Three distinct archetypes of dyadic contributions to heart failure care were observed that represent a gradient in the level of contributions to self-care, in addition to different approaches to working together to manage heart failure. Interventions and clinical programs that involve heart failure dyads should tailor strategies to take into consideration these distinct archetypes and their attributes.

Dyadic Heart Failure Care Types: Qualitative Evidence for a Novel Typology

Background:Compared with other chronic illness populations, relatively little is known about heart failure (HF) patient and caregiver spousal/partner dyads and what effect dyadic interactions have on self-care. Objective:The aim of this study was to present a new typology of patient and caregiver dyadic interdependence in HF care, presenting exemplar cases of each type: patient oriented, caregiver oriented, collaboratively oriented, complementarily oriented. Methods:Stake’s instrumental case study methodology was used. Interviews were unstructured, consisting of open-ended questions exploring dyad’s experiences with HF, audiorecorded, and transcribed. Cases were selected because they exhibited the necessary characteristics and also highlighted a unique, little understood variation in self-care practice. Each case represents a dyad’s discussion of caring for HF in their normal environment. Results:From 19 dyads, 5 exemplar case studies illustrate the 4 dyadic types. A fifth, incongruent case, defined as a case where the patient and caregiver indicated incongruent dyadic types, was included to highlight that not all dyads agree on their type. A major theme of Sharing Life infused all of the dyad’s narratives. This typology advances the science of dyadic interdependence in HF self-care, explains possible impact on outcomes, and is an early theoretical conceptualization of these complex and dynamic phenomena. Conclusion:The cases illustrate how long-term dyads attempt to share the patient’s HF care according to established patterns developed over the trajectory of their relationship. In keeping with the interdependence theory, these couples react to the patient’s declining ability to contribute to his/her own care by maintaining their habitual pattern until forced to shift. This original pattern may or may not have involved the dyad working together. As the patient’s dependence on the caregiver increases, the caregiver must decide whether to react out of self-interest or the patient’s interest. Continued study of the typology is needed in nonspousal/partner dyads.

Heart failure management in skilled nursing facilities: A scientific statement from the American Heart Association and the Heart Failure Society of America

655 Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age. Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common. Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management. Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites. Transitions between hospitals and SNFs may be problematic. SNF 30-day rehospitalization rates for HF range from 27% to 43%, and long-term care residents sent to the emergency department are at increased risk for hospital admission and death. The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patientcentered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting.

Predictors of hospitalization and quality of life in heart failure: A model of comorbidity, self-efficacy and self-care

BACKGROUND Comorbidity is associated with decreased confidence or self-efficacy to perform self-care in heart failure patients which, in turn, impairs self-care behaviors. Comorbidity is also associated with increased hospitalization rates and poorer quality of life. Yet the manner in which comorbidity and self-efficacy interact to influence self-care, hospitalization, and quality of life remains unclear. OBJECTIVES The purpose of this study was to test an explanatory model. The research questions were (1) What is the contribution of comorbidity to heart failure self-care behaviors and outcomes (i.e. hospitalization, quality of life)? and (2) Is comorbidity a moderator of the relationship between self-efficacy and heart failure self-care behaviors? DESIGN This was an analysis of an existing dataset of 628 symptomatic, older (mean age=73, standard deviation (SD)=11) male (58%) Italian heart failure patients using structural equation modeling and simple slope analysis. RESULTS Higher levels of self-care maintenance were associated with higher quality of life and lower hospitalization rates. Higher levels of comorbidity were associated with lower levels of self-care management. Comorbidity moderated the relationship between self-efficacy and self-care maintenance, but not self-care management. Post hoc simple slopes analysis showed significantly different slope coefficients (pdiff<.05). Specifically, in patients with less comorbidity, the relationship between self-efficacy and self-care was significantly stronger than in patients with higher comorbidity. CONCLUSIONS Self-efficacy is important in the self-care maintenance process at each level of comorbidity. Because higher comorbidity weakens the strength of the relationship between self-efficacy and self-care maintenance, tailoring interventions aimed at improving self-efficacy to different levels of comorbidity may be key to impacting hospitalization and quality of life.

The key role of caregiver confidence in the caregiver’s contribution to self-care in adults with heart failure:

Background: Caregivers play an important role in contributing to heart failure (HF) patients’ self-care but no prior studies have examined the caregivers’ contributions to HF patients’ self-care and no prior studies have examined potential determinants of the caregivers’ contribution to HF patients’ self-care. Aims: The purpose of this study was to describe the caregivers’ contribution to HF patients’ self-care and identify its determinants. Methods: The study design involved a secondary analysis of cross-sectional data. Caregivers’ contributions were measured with the Caregiver’s Contribution to Self-care of HF Index (CC-SCHFI) which measures the caregiver’s contribution to self-care maintenance and management and caregiver confidence in contributing to HF patient’s self-care. Potential determinants were measured using a socio-demographic questionnaire completed by caregivers and patients, and patient clinical data was obtained from the medical record. Results: Data from 515 caregiver/patient dyads were analyzed. Most (55.5%) patients were male (mean age 75.6 years) and most (52.4%) caregivers were female (mean age, 56.6 years). The caregivers’ contribution to patients’ self-care maintenance was low in weight monitoring and physical activity but higher in checking ankles, advising on low-salt foods and taking medicines. The caregivers’ contribution to patients’ self-care management was low in symptom recognition. When symptoms were recognized, caregivers advised patients to reduce fluids and salt and call the provider but rarely advised to take an extra diuretic. Caregiver confidence in the ability to contribute to patient self-care explained a significant amount of variance in the caregiver’s contribution. Conclusion: These findings suggest that caregivers in this sample did not contribute meaningfully to HF self-care. Providers should educate both HF patients and caregivers. Interventions that improve caregiver confidence have the potential to successfully increase the caregivers’ contribution to patients’ self-care.

Heart Failure Management in Skilled Nursing Facilities A Scientific Statement From the American Heart Association and the Heart Failure Society of America

Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age.1 Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common.2,3 Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management.4–6 Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites.7 Transitions between hospitals and SNFs may be problematic.8 SNF 30-day rehospitalization rates for HF range from 27% to 43%,7,9,10 and long-term care residents sent to the emergency department are at increased risk for hospital admission and death.11 The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patient-centered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting. This scientific statement on HF management in SNFs was developed by a writing group of experts representing nursing, medicine (cardiology, geriatrics, nursing home physicians, and palliative medicine), pharmacology, physical therapy, dietary clinical management, research, and …