Martha Shively

The Minnesota Living with Heart Failure Questionnaire: Sensitivity to differences and responsiveness to intervention intensity in a clinical population

BackgroundThe Minnesota Living With Heart Failure Questionnaire (LHFQ) is a commonly used measure of health-related quality of life in persons with heart failure. Researchers have questioned whether LHFQ is sensitive to subtle differences and sufficiently responsive to clinical interventions because the instrument has demonstrated variable performance in clinical trials. ObjectivesA secondary analysis was conducted to assess the LHFQ for sensitivity to different clinical states and responsiveness to varying intensities of clinical intervention. MethodsA convenience sample of nine experimental or quasi-experimental studies from eight clinical sites in the United States yielded data from 1,136 patients with heart failure. Data in the studies had been collected at enrollment and one, three, and/or six months later. Data were analyzed using descriptive, univariate, and multivariate techniques. ResultsTotal and subscale scores on LHFQ were poorer in those with worse New York Heart Association functional class, although there was no difference in LHFQ scores between classes III and IV. No difference in LHFQ scores was found when patients were classified by ejection fraction. Scores improved significantly following hospital discharge, even in those in the control group. Changes in LHFQ scores were greatest in those receiving high intensity interventions. ConclusionsThe LHFQ is sensitive to major differences in symptom severity but may not be sensitive to subtle differences. It is responsive to high intensity interventions. Investigators are cautioned against using this instrument without first maximizing intervention power or without a control group for comparison.

Effect of patient activation on self-management in patients with heart failure.

Background/Objective:Few studies have examined whether chronic heart failure (HF) outcomes can be improved by increasing patient engagement (known as activation) in care and capabilities for self-care management. The objective was to determine the efficacy of a patient activation intervention compared with usual care on activation, self-care management, hospitalizations, and emergency department visits in patients with HF. Methods:This study used a randomized, 2-group, repeated-measures design. After consent was given, 84 participants were stratified by activation level and randomly assigned to usual care (n = 41) or usual care plus the intervention (n = 43). The primary outcomes and measures were patient activation using the Patient Activation Measure (PAM), self-management using the Self-Care of Heart Failure Index (SCHFI) and the Medical Outcomes Study (MOS) Specific Adherence Scale, and hospitalizations and emergency department visits. The intervention was a 6-month program to increase activation and improve HF self-management behaviors, such as adhering to medications and implementing health behavior goals. Results:Participants were primarily male (99%), were white (77%), and had New York Heart Association III stage (52%). The mean (SD) age was 66 (11) years, and 71% reported 3 or more comorbidities. The intervention group compared with the usual care group showed a significant increase in activation/PAM scores from baseline to 6 months. No significant group-by-time interactions were found for the SCHFI scales. Although the baseline MOS Specific Adherence Scale mean was lower in the intervention group, results showed a significant group-by-time effect with the intervention group improving more over time. Participants in the intervention group had fewer hospitalizations compared with the usual care group when the baseline activation/PAM level was low or high. Conclusion:This study supports the importance of targeted interventions to improve patient activation or engagement in HF care. Further work is needed related to HF self-management measurement and outcomes.

Effects of Spiritual Mantram Repetition on HIV Outcomes: A Randomized Controlled Trial

We examined the efficacy of a psycho-spiritual intervention of mantram repetition—a word or phrase with spiritual associations repeated silently throughout the day–on psychological distress (intrusive thoughts, stress, anxiety, anger, depression), quality of life enjoyment and satisfaction, and existential spiritual well-being in HIV-infected adults. Using a 2-group by 4-time repeated measures design, 93 participants were randomly assigned to mantram (n = 46) or attention control group (n = 47). Over time, the mantram group improved significantly more than the control group in reducing trait-anger and increasing spiritual faith and spiritual connectedness. Actual mantram practice measured by wrist counters was inversely associated with non-HIV related intrusive thoughts and positively associated with quality of life, total existential spiritual well-being, meaning/peace, and spiritual faith. Intent-to-treat findings suggest that a mantram group intervention and actual mantram practice each make unique contributions for managing psychological distress and enhancing existential spiritual well-being in adults living with HIV/AIDS.

A Real-Time Assessment of Work Stress in Physicians and Nurses

OBJECTIVE This study adapted ecological momentary assessment methods to: (a) examine differences in work stress between nurses and physicians, and (b) to study relationships between work stress, work activity patterns, and sleep. DESIGN A total of 185 physicians and 119 nurses (206 women, 98 men) working in four teaching hospitals participated in an observational study of work stress. MAIN OUTCOME MEASURES Participants carried handheld computers that randomly prompted them for work activity, patient load, and work stress information. RESULTS Participants completed more than 9,500 random interval surveys during the study (an average of 30.8 surveys per person-week). Approximately 85% of all surveys were completed in full (73.3%) or partially (11.6%). Emotional stress scores among physicians were nearly 50% higher (26.9[19.0]) than those of nurses (18.1[14.9], r[302] = .37, p < .001). Direct and indirect care activities were associated with higher stress reports by both clinician groups (rs[159] = .14-.26, ps < .01). Sleep quality and quantity were predictors of work stress scores (ps < .05). Finally, higher work stress and lower sleep quality were also associated with poorer memory performance (r[302] = -.12, .17, ps < 05). CONCLUSIONS The findings identify patterns of work stress in relationship to work activities, sleep habits, and provider differences that may be used to assist ongoing hospital work reform efforts.

Ethnic differences in quality of life in persons with heart failure

BACKGROUND Chronic illness burdens some groups more than others. In studies of ethnic/racial groups with chronic illness, some investigators have found differences in health-related quality of life (HRQL), whereas others have not. Few such comparisons have been performed in persons with heart failure. The purpose of this study was to compare HRQL in non-Hispanic white, black, and Hispanic adults with heart failure. METHODS Data for this longitudinal comparative study were obtained from eight sites in the Southwest, Southeast, Northwest, Northeast, and Midwest United States. Enrollment and 3- and 6-month data on 1212 patients were used in this analysis. Propensity scores were used to adjust for sociodemographic and clinical differences among the ethnic/racial groups. Health-related quality of life was measured using the Minnesota Living with Heart Failure Questionnaire. RESULTS Significant ethnic/racial effects were demonstrated, with more favorable Minnesota Living with Heart Failure Questionnaire total scores post-baseline for Hispanic patients compared with both black and white patients, even after adjusting for baseline scores, age, gender, education, severity of illness, and care setting (acute vs. chronic), and estimating the treatment effect (intervention vs. usual care). The models based on the physical and emotional subscale scores were similar, with post hoc comparisons indicating more positive outcomes for Hispanic patients than non-Hispanic white patients. CONCLUSION Cultural differences in the interpretation of and response to chronic illness may explain why HRQL improves more over time in Hispanic patients with heart failure compared with white and black patients.

Intern to Attending: Assessing Stress Among Physicians

Purpose Organizations have raised concerns regarding stress in the medical work environment and effects on health care worker performance. This studys objective was to assess workplace stress among interns, residents, and attending physicians using Ecological Momentary Assessment technology, the gold-standard method for real-time measurement of psychological characteristics. Method The authors deployed handheld computers with customized software to 185 physicians on the medicine and pediatric wards of four major teaching hospitals. The physicians contemporaneously recorded multiple dimensions of physician work (e.g., type of call day), emotional stress (e.g., worry, stress, fatigue), and perceived workload (e.g., patient volume). The authors performed descriptive statistics and t test and linear regression analyses. Results Participants completed 5,673 prompts during an 18-month period from 2004 to 2005. Parameters associated with higher emotional stress in linear regression models included male gender (t = −2.5, P = .01), total patient load (t = 4.2, P < .001), and sleep quality (t = −2.8, P = .006). Stress levels reported by attendings (t = −3.3, P = .001) were lower than levels reported by residents (t = −2.6, P = .009), and emotional stress levels of attendings and residents were both lower compared with interns. Conclusions On inpatient wards, after recent resident duty hours changes, physician trainees continue to show wide-ranging evidence of workplace stress and poor sleep quality. This is among the first studies of medical workplace stress in real time. These results can help residency programs target education in stress and sleep and readdress workload distribution by training level. Further research is needed to clarify behavioral factors underlying variability in housestaff stress responses.

Measurement of Fatigue in HIV-Positive Adults: Reliability and Validity of the Global Fatigue Index

Fatigue is among the most common and distressing symptoms in patients with HIV/AIDS. Little is known about the clinical assessment of fatigue, especially in patients using highly active antiretroviral regimens. The purpose of this study was to evaluate the psychometric properties of the Global Fatigue Index (GFI) in a community-based sample of 209 patients with HIV/AIDS. The GFI is a measure that quantifies five dimensions of fatigue from the Multidimensional Assessment of Fatigue instrument into one score. To assess construct validity, the study included measures of depression, perceived stress, activities of daily living (ADLs), health behaviors, and clinical markers. Cronbachs alpha was calculated for internal consistency reliability, and factor analysis and bivariate correlations were conducted. The GFI was found to be easily self-administered, reliable, and a valid measure of overall fatigue burden in an HIV population. This instrument may be used by clinicians and researchers for assessing fatigue.

Improving quality of life in patients with heart failure: an innovative behavioral intervention.

Nurses play a major role in assisting patients with chronic diseases manage their symptoms, adhere to treatment, and change behavior. This article describes an innovative behavioral intervention for patients with heart failure. The rationale and theoretical basis for the intervention, implementation, and evaluation of the intervention and its implications for use in clinical practice and further research are presented.

Testing a community level research utilization intervention

Research supports changing practice from heparinized to saline flushes for adults, yet heparin continues to be used in clinical practice. The primary aim of this study was to test the effectiveness of a community level innovation diffusion intervention as a method of stimulating research utilization at three acute care facilities in one community simultaneously. The change advocated was the flushing of intermittent intravenous devices (IID) with saline rather than heparin. Pilot IID units were chosen on which to test the change from the use of heparin to saline flushes. The innovation focused on staff empowerment and was implemented in five phases. The change to saline flushes was successful and has been maintained.

Real‐Time Assessment of Nurse Work Environment and Stress

&NA; Ecological momentary assessment methods were used to examine real–time relationships between work environment factors and stress in a sample of 119 registered nurses (RNs) in acute and critical care settings of three hospitals. The RNs carried handheld computers for 1 week of work shifts and were randomly surveyed within 90–min intervals to self–report work activity, perceived workload, and stress. Mixed effects linear regression analyses were completed to predict the stress score in the sample. The number of patients assigned significantly predicted stress; the greater the number of assigned patients, the higher the reported stress (p<.01). Age, gender, adult versus pediatric facility type, familiarity with patients, and proportion of direct care tasks were not significant predictors of stress. Further research is needed to link work environment factors and stress with errors among nurses.