Living with heart failure: An integrative review

Development of a scale to gain insight into the experience of living with chronic heart failure: The UNAV-Experience of Living with Chronic Heart Failure Scale

BACKGROUND

To date, there are no tools for the nursing staff to gain systematic insight on the experience lived by patients with chronic heart failure. The objective of this study was to develop a scale for this purpose.

METHODS

The study was conducted between January 2018 and December 2020 in three Spanish hospitals. The process described by DeVellis was used for the development of the scale. The items were built based on a phenomenological study and a systematic review of the literature. Next, feedback from a panel of experts was obtained, the scale was administered to a sample of patients with chronic heart failure, and a cognitive interview and an observational study were conducted to create the final version of the scale.

RESULTS

The first version of the scale had in seven domains and 76 items. After its evaluation by a panel of experts, it was reduced to a second version with six domains and 55 items. Following the administration of Version 2 to 17 patients (58.8% male, mean age 59.53, 70.6% classified as NYHA functional class II), five items were modified and two eliminated. Thus, the third version of the UNAV-CHF Experience Scale was composed of six domains and 53 items.

CONCLUSIONS

This study presents the development of the UNAV-experience of living with chronic heart failure scale. It is an original and novel instrument that allows systematically explore this experience. A larger-scale study is necessary to confirm the validity of our scale.

Lived Experience of Adult With Heart Failure at Tibebe Ghion Specialized Teaching Hospital Northwest Ethiopia, Qualitative Phenomenological Study

Background

Heart failure is major public health problem that affects many people worldwide. It affects all aspects of patients' lives, leading to extreme physical, social, and functional restriction and increasing psychological distress. The purpose of this study was to explore the lived experience of adult patient with heart failure at Tibebe Ghion Specialize Hospital, Ethiopia, 2022.

Method

Qualitative Phenomenological study design was conducted at Tibebe Ghion Specialized Referral Hospital, from November 10 to December 15, 2022. Heterogenous purposive sampling technique was used to select 11 study participants. Data were collected through in-depth interviews guides and observational checklist. The rigor and trustworthiness of the study were maintained by transferability, dependability, credibility, and conformability. Thematic analysis method was used for the development of codes and themes using ATLAS. ti.7 software for analysis.

Result

Five main themes and eleven subthemes were developed that explore the lived experience of adults with heart failure. Impact of heart failure on daily life, psychological and spiritual experiences, financial experiences, experiences related to hospital service, and challenges to getting treatment are major themes. Unavailability of medicine, lab investigations, and the inaccessibility of cardiac centers were the main challenges during their treatment.

Conclusion

This study explored that lived experience of adult HF patients were addressed in in terms of Physical, Psychological and Spiritual, financial, hospital service and challenges to get treatment. Therefore, we recommended providing psychological and economical support for HF patients and in addition to accessing medication and medical care centers.

Caregiver Burden in Adult Solid Organ Transplantation

The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.

Experiencing the possibility of near death on a daily basis: A phenomenological study of patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is a syndrome that greatly impacts people's lives. Due to the poor prognosis of CHF, together with the frequent exacerbations of symptoms, death is a topic that is very present in the lives of patients with CHF.

OBJECTIVE

To explore thoughts about death experienced by patients with chronic heart failure in their daily lives.

METHODS

A hermeneutic phenomenological study was carried out. Conversational interviews were conducted with 20 outpatients with chronic heart failure. Analysis of the responses was based on the method proposed by van Manen.

RESULTS

From the analysis, four main themes emerged: (1) Feeling afraid of the possibility of dying; (2) Acceptance of the possibility of death; (3) Desiring death for relief from suffering; and (4) Striving to continue living to enjoy family.

CONCLUSIONS

This study presents, as a novel finding, that people with CHF experience the possibility of near death on a daily basis. This experience, which they must encounter on their own, makes them afraid. In addition, some of them, in view of the discomfort they are living, wish to die, with some even considering committing suicide.

Do chronic heart failure symptoms interact with burden of treatment? Qualitative literature systematic review

OBJECTIVE

Explore the interaction between patient experienced symptoms and burden of treatment (BoT) theory in chronic heart failure (CHF). BoT explains how dynamic patient workload (self-care) and their capacity (elements influencing capability), impacts on patients' experience of illness.

DESIGN

Review of qualitative research studies.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsycINFO, Scopus and Web of Science were searched between January 2007 and 2020.

ELIGIBILITY CRITERIA

Journal articles in English, reporting qualitative studies on lived experience of CHF.

RESULTS

35 articles identified related to the lived experience of 720 patients with CHF. Symptoms with physical and emotional characteristics were identified with breathlessness, weakness, despair and anxiety most prevalent. Identifying symptoms' interaction with BoT framework identified three themes: (1) Symptoms appear to infrequently drive patients to engage in self-care (9.2% of codes), (2) symptoms appear to impede (70.5% of codes) and (3) symptoms form barriers to self-care engagement (20.3% of codes). Symptoms increase illness workload, making completing tasks more difficult; simultaneously, symptoms alter a patient's capacity, through a reduction in their individual capabilities and willingness to access external resources (ie, hospitals) often with devasting impact on patients' lives.

CONCLUSIONS

Symptoms appear to be integral in the patient experience of CHF and BoT, predominately acting to impede patients' efforts to engage in self-care. Symptoms alter illness workload, increasing complexity and hardship. Patients' capacity is reduced by symptoms, in what they can do and their willingness to ask for help. Symptoms can lower their perceived self-value and roles within society. Symptoms appear to erode a patient's agency, decreasing self-value and generalised physical deconditioning leading to affective paralysis towards self-care regimens. Together describing a state of overwhelming BoT which is thought to be a contributor to poor engagement in self-care and may provide new insights into the perceived poor adherence to self-care in the CHF population.

PROSPERO REGISTRATION NUMBER

CRD42017077487.

Psychometric Validation of the Living with Chronic Illness Scale in Patients with Chronic Heart Failure

It is necessary to develop self-reported instruments that evaluate the process of living with chronic heart failure (HF) holistically. The Living with Chronic Illness Scale—HF (LW-CI-HF) is the only available tool to evaluate how patients are living with HF. The aim is to analyse the psychometric properties of the LW-CI scale in the HF population. An international, cross-sectional validation study was carried out in 603 patients living with HF from Spain and Colombia. The variables measured were living with HF, perceived social support, satisfaction with life, quality of life and global impression of severity. The LW-CI-HF scale presented good data quality and acceptability. All domains showed high internal consistency with Cronbach’s alpha coefficient ≥ 0.7. The intraclass correlation coefficient for the total score was satisfactory (0.9) in test–retest reliability. The LW-CI-HF correlated 0.7 with social support and quality of life measures. Standard error of measurement was 6.5 for total scale. The LW-CI-HF scale is feasible, reliable and valid. However, results should be taken with caution in order to be used in clinical practice to evaluate the complex process of living with HF. Further research is proposed.

Living with heart failure: perspectives of ethnic minority families

Background

The family perspective on heart failure (HF) has an important role in patients’ self-care patterns, adjustment to the disease and quality of life. Little is known about families’ experiences of living with HF, particularly in ethnic minority families. This study describes the experiences of Iranian families living with HF as an ethnic minority family in Denmark.

Methods

In this descriptive qualitative study, we conducted eight face-to-face joint family interviews of Iranian patients with HF and their family members living in Denmark. We used content analysis with an inductive approach for data analysis.

Results

We identified three categories: family daily life, process of independence and family relationships. Families were faced with physical restrictions, emotional distress and social limitations in their daily lives that threatened the patients’ independence. Different strategies were used to promote independence. One strategy was normalisation and avoiding the sick role; another strategy was accepting and adjusting themselves to challenges and limitations. The independence process itself had an impact on family relationships. Adjusting well to the new situation strengthened the relationship, while having problems in adjustment strained the relationship within the family.

Conclusions

This study highlights the process of independence as perceived by families living with HF. It is crucial to both families and healthcare professionals to maintain a balance between providing adequate support and ensuring independence when dealing with patients with HF. Understanding patients’ stories and their needs seems to be helpful in gaining this balance.

The impact of psychoeducational interventions on the outcomes of caregivers of patients with heart failure: A systematic review and meta-analysis

BACKGROUND

Heart failure is a global health care problem that causes a significant economic burden. Despite medical advancements, it's prognosis remains poor as many patients with heart failure experience symptoms that negatively impact Quality of Life. Caregivers are often responsible for helping and supporting family members manage their heart failure symptoms at home. In addition to managing their own medical problems and maintaining social and personal lives, significant burden and stress can occur. At present, caregivers receive little guidance or information to support them in their caregiving role.

OBJECTIVES

This review aims to determine the impact of psychoeducational interventions on the outcomes of caregivers of patients with heart failure.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Five electronic databases: PsycINFO, Medline, CINAHL Plus, EMBASE and SCOPUS were searched from June 2007 to August 2019.

REVIEW METHODS

The conduct and reporting of this review was based on the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The Cochrane Risk of Bias Tool was used to assess the risk of bias amongst randomised controlled trials, and the Newcastle Ottawa Scale was used to assess risk of bias in one quasi-experimental study.

RESULTS

Ten articles met the inclusion criteria, consisting of seven studies, with a total sample size of 953 participants. The pooled result from two studies, conducted in America and China, reported that psychoeducational interventions significantly reduced depression at six months' follow-up (SMD -0.82; 95% CI -1.17 to -0.47; p = 0.73, I² =0%). The pooled result from two studies conducted in Sweden and Taiwan showed a significant improvement in heart failure knowledge at six months' follow-up (SMD 0.97; 95% CI 0.70 to 1,25; p < 0.00001, I² =0%). Finally, pooled results from three studies conducted in Sweden, China and Taiwan found a significant improvement in Quality of Life at 3 months' follow- up (SMD 0.25; 95% CI 0.25 to 0.48; p = 0.03). The three most common intervention components included: group based educational sessions, telemonitoring and telephone support, and written resources.

CONCLUSIONS

There was no specific type of psychoeducational intervention found to have a significant impact on caregiver outcomes, as interventions were heterogeneous consisting of multiple components. Further research is needed to determine the effectiveness of individual and combined components to identify the ideal intervention format and design for caregivers of patients with heart failure.

Theory-guided interventions for Chinese patients to adapt to heart failure: A quasi-experimental study

Objectives

To examine the effects of the Roy Adaptation Model-based interventions on adaptation in persons with heart failure.

Methods

A quasi-experimental study was conducted in Hangzhou, China, from March 2018 to November 2019. A convenience sample of 112 participants with heart failure from a multi-campus hospital was enrolled. Participants were allocated into an intervention group (n = 55) and a control group (n = 57) according to their hospitalized campus. A culturally-tailored care plan intervention based on the Roy Adaptation Model was performed in the intervention group. The control group received bedside patient education and a regular booklet for HF home care before discharge. Heart ultrasound, Minnesota Living with Heart Failure Questionnaire (MLHFQ), a knowledge survey, Self-care Heart failure Index (SCHFI), and Coping and Adaptation Processing Scale-Short Form (CAPS-SF) were used to measure patients’ levels of adaptation of physical function, self-concept, role function, and interdependence at baseline and six months after discharge.

Results

Ninety-one participants with complete data, 43 in the intervention group and 48 in the control group, were included in the analysis for the primary endpoints and showed adaptive improvement trends. Most patients in the intervention group completed 60% or more of the given interventions. At the sixth month after discharge, compared with the control group, the intervention group had improved adaptive behaviors showing higher scores of the MLHFQ (70.90 ± 22.45 vs. 54.78 ± 18.04), heart failure-related knowledge (13.79 ± 2.45 vs. 10.73 ± 4.28), SCHFI maintenance (57.67 ± 13.22 vs. 50.35 ± 10.88), and CAPS-SF (40.23 ± 4.36 vs. 38.27 ± 2.60) at the six-month follow-up (P ＜ 0.05). There were no significant differences between the two groups in the scores of left ventricular ejection fraction, scores of SCHFI management and SCHFI confidence subscales (P > 0.05).

Conclusions

The findings reported evidence of positive adaptation in patients with heart failure, indicating that the Roy Adaptation Model is an effective guide for developing an implemented framework for the nursing practice of the patients. The culturally-tailored care plan intervention is helpful to improve adaptation of patients with heart failure.

Identifying unique profiles of perceived dyspnea burden in heart failure

BACKGROUND

Dyspnea is a common symptom of heart failure (HF) but dyspnea burden is highly variable.

OBJECTIVES

Identify distinct profiles of dyspnea burden and identify predictors of dyspnea symptom profile.

METHODS

A secondary analysis of data from five studies completed at Oregon Health and Science University was conducted. The Heart Failure Somatic Perception Scale was used to measure dyspnea burden. Latent class mixture modeling identified distinct profiles of dyspnea burden in a sample of HF patients (n = 449). Backwards stepwise multinomial logistic regression identified predictors of latent profile membership.

RESULTS

Four profiles of dyspnea burden were identified: no dyspnea/not bothered by dyspnea, mild dyspnea, moderate exertional dyspnea, and moderate exertional dyspnea with orthopnea and PND. Higher age was associated with greater likelihood of not being bothered by dyspnea than having moderate exertional dyspnea with orthopnea and PND. Higher NYHA class, anxiety, and depression were associated with greater likelihood of greater dyspnea burden.

CONCLUSIONS

Burden of dyspnea is highly variable among HF patients. Clinicians should account for the nuances of dyspnea and the activities that induce dyspnea when assessing HF patients.

Perceived benefits of the disease: A qualitative study of patients' experiences of heart failure

Heart failure may bring about positive outcomes, which have not been adequately addressed in the literature. Therefore, this qualitative study sought to scrutinize the experiences of patients and the perceived positive effects of heart failure. The opinions of 19 patients with heart failure in Mashhad city (Iran) were collected via semistructured interviews from December 2017 to November 2018. After analyzing the data, six themes were identified by framework analysis: healthy lifestyle, effective interactions, appreciation of life, spirituality, reappraisal of life and priorities, and endurance. Such positive effects may lead to empowerment and better coping of patients with the disease. Therefore, nurses should consider the patients' perception of illness in addition to the disease manifestations and offer training focusing on the possibilities instead of limitations.

Unexplored Aspects of the Meaning of Living with Chronic Heart Failure: A Phenomenological Study within the Framework of the Model of Interpersonal Relationship between the Nurse and the Person/Family Cared for

The complicated situation experienced by chronic heart failure (CHF) patients affects their entire well-being but clinical practice continues to fail to adequately respond to their demands. The aim of this study was to understand the meaning of living with CHF from the patient's perspective. A hermeneutic phenomenological study was conducted according to Van Manen's phenomenology of practice method. Individual conversational interviews were held with 20 outpatients with CHF. Six main themes emerged from the analysis: (1) Living with CHF involves a profound change in the person; (2) The person living with CHF has to accept their situation; (3) The person with CHF needs to feel that their life is normal and demonstrate it to others; (4) The person with CHF needs to have hope; (5) Having CHF makes the person continuously aware of the possibility of dying; (6) The person with CHF feels that it negatively influences their close environment.

Chinese Hospitalized Cardiovascular Patients' Attitudes Towards Self-Management: A Qualitative Study

PURPOSE

This study is aiming to investigate cardiovascular patients' attitudes towards self-management during hospitalization in China.

PATIENTS AND METHODS

Twenty-nine individuals living with cardiovascular disease from one designated Cardiology Department in Hangzhou, China, were recruited through a purposive sampling procedure. A qualitative descriptive methodology was used. Semi-structured interviews were also used to gain attitudes toward self-management. The interviews were audio-recorded, transcribed and analyzed by thematic analysis to develop the results.

RESULTS

Four themes were identified from the qualitative data: (1): Responsibilities of self-management; (2): Reflections on self-management; (3): Acknowledgement of self-management support; (4): Challenges in implementing and adherence to self-management. Additionally, interview data were also given to illustrate these main themes emerging during the analysis. Patients gradually took their responsibilities to manage chronic symptoms. During their self-management process, they did reflections to help correct their regiments through supportive interactions. Health system responsiveness, health disparities, social capital, and cultural setting were the main external factors influencing better self-management implementation and adherence.

CONCLUSION

This study revealed the hospitalized cardiovascular patients' attitudes towards self-management in China. These findings emphasized the importance of patients' responsibility, reflections, and various social support receiving and pointed out specific external factors influencing the health outcomes and their quality of life. This study also proves the guide for the policymakers and health system better instructions to develop individually and culturally tailored advanced self-management interventions and programs.

Health literacy, multimorbidity, and patient-perceived treatment burden in individuals with cardiovascular disease. A Danish population-based study

OBJECTIVE

The aim was to investigate the association between: 1) multimorbidity and high treatment burden 2) health literacy and high treatment burden, and 3) the interaction between multimorbidity and health literacy in relation to high treatment burden.

METHODS

We included respondents with cardiovascular disease who participated in a Danish population-based survey from 2017 (N = 2,111). Logistic regression analyses were used to study associations.

RESULTS

The study showed that multimorbid individuals with cardiovascular disease were more likely to experience a high treatment burden than individuals with cardiovascular disease only (2+ additional conditions OR 4.16 [2.80-6.18]). Also, individuals with difficulties in understanding health information were more likely to report a high treatment burden than individuals who found it easy to understand information about health (OR 9.97 [6.23-15.95]). Finally, individuals with multimorbidity and difficulties in understanding health information had markedly higher odds of experiencing a high treatment burden.

CONCLUSION

If individuals find it difficult to understand health information, there is a risk they might feel overwhelmed by the treatment.

PRACTICE IMPLICATIONS

Healthcare professionals should be aware of health literacy challenges in planning medical treatment particularly for patients with both low health literacy levels and multimorbidity.

Perceptions of a Good Death in Children with Life-Shortening Conditions: An Integrative Review

Background: For children with life-shortening illness, achieving a "good death" can be a tacit goal. There is little understanding of how different stakeholders perceive what a "good death" might be. Objective: To review empirical literature to construct an understanding of a "good death" for children with life-shortening conditions. Design: An integrative review approach was followed. This involved searching across Embase, Web of Science, Medline, CINAHL, and PsycINFO (no date limits set), as well as identifying eligible studies tracking reference lists. Appraisal of shortlisted articles in full text was performed, followed by data extraction, synthesis, and interpretation. Results: Analysis of articles (n = 24) yielded a dynamic and layered narrative about a good death that revolved around three themes. (1) Level of needs: includes both practical support and aspirational goals such as "do everything." (2) The composite experience: whether positive or negative adds to produce a sense of suffering. (3) Control (preservation and letting go): moving from maintaining status quo to acceptance of the child's death, the experience of which also contributes to suffering. Framed using a health care system perspective, a concept map that interprets a good death in children with life-shortening conditions is represented. Conclusions: A single yet holistic understanding of a good death experienced in the "real world" is suggested. Pediatric health and social care providers, and even policy makers, can use this new understanding to conceive alternative approaches to enhance support to dying children and their families.

Naive Expectations to Resignation: A Comparison of Life Descriptions of Newly Diagnosed Versus Chronic Persons Living With Stage D HF

Purpose

This study examined life descriptions of persons with stage D heart failure (HF) comparing those newly diagnosed to those with chronic HF.

Methods

A secondary analysis of interviews from 75 participants followed in a longitudinal study of persons with stage D HF was thematically analyzed. There were 24 participants who were recently diagnosed with stage D HF (less than 2 years) and 51 participants with HF longer than 2 years.

Results

Both groups shared life descriptions along a continuum, where recently diagnosed participants described naive expectations with hope for improvement, while the chronic group appeared resigned to their fate and the reality of the limitations of living with HF. Four themes illustrated differences between the groups: outlook on life, activity adjustments, understanding of HF, and mood.

Conclusions

Although persons with stage D HF share the same life descriptions, they have differing perspectives of life with HF. Findings from this study can help health-care providers tailor interventions based on the length of time from diagnosis.

'The importance of planning for the future': Burden and unmet needs of caregivers' in advanced heart failure: A mixed methods study

BACKGROUND

While studies have evaluated caregiver outcomes in heart failure, the burden and support needs when caring for someone with advanced heart failure at the end of life have yet to be outlined.

AIM

To identify psychosocial factors associated with caregiver burden and evaluate the support needs of caregivers in advanced heart failure.

DESIGN

A sequential mixed methods study comprising two phases: (1) postal survey with advanced heart failure patients and their caregivers and (2) interviews with current and bereaved caregivers. Correlation, chi-square, t test, regression and thematic analysis were undertaken on the data.

PARTICIPANTS

Advanced heart failure patients ( n = 112) and their caregivers ( n = 84) were recruited from secondary care settings across the United Kingdom and Ireland. For phase 2 interviews, current caregivers ( n = 20) were purposively recruited from phase 1, and bereaved caregivers ( n = 10) were purposively recruited via voluntary organisation, social media and email.

RESULTS

More than half the caregivers (53%) had levels of distress associated with depression (Zarit Burden score >24). Caregiver depression score, preparedness for caregiving and patients' depression score predicted caregiver burden. Qualitative analysis identified an overarching theme of lack of future care planning and four subthemes: (1) seeking emotional support from someone who understands, (2) want information on prognostication, (3) lack of knowledge on how to and where to get support and (4) require knowledge on what to expect at the end of life.

CONCLUSION

Caregivers have unmet needs and feel unprepared for the future. Implementation of future care planning by clinical teams should address patient and caregiver support needs and in turn alleviate caregiver burden.

Managing expectations: cognitive authority and experienced control in complex healthcare processes

Background

Balancing the normative expectations of others (accountabilities) against the personal and distributed resources available to meet them (capacity) is a ubiquitous feature of social relations in many settings. This is an important problem in the management of long–term conditions, because of widespread problems of non-adherence to treatment regimens. Using long-term conditions as an example, we set out middle range theory of this balancing work.

Methods

A middle-range theory was constructed four stages. First, a qualitative elicitation study of men with heart failure was used to develop general propositions about patient and care giver experience, and about the ways that the organisation and delivery of care affected this. Second, these propositions were developed and confirmed through a systematic review of qualitative research literature. Third, theoretical propositions and constructs were built, refined and presented as a logic model associated with two main theoretical propositions. Finally, a construct validation exercise was undertaken, in which construct definitions informed reanalysis of a set of systematic reviews of studies of patient and caregiver experiences of heart failure that had been included in an earlier meta-review.

Results

Cognitive Authority Theory identifies, characterises and explains negotiation processes in in which people manage their relations with the expectations of normative systems – like those encountered in the management of long-term conditions. Here, their cognitive authority is the product of an assessment of competence, trustworthiness and credibility made about a person by other participants in a healthcare process; and their experienced control is a function of the degree to which they successfully manage the external process-specific limiting factors that make it difficult to otherwise perform in their role.

Conclusion

Cognitive Authority Theory assists in explaining how participants in complex social processes manage important relational aspects of inequalities in power and expertise. It can play an important part in understanding the dynamics of participation in healthcare processes. It suggests ways in which these burdens may lead to relationally induced non-adherence to treatment regimens and self-care programmes, and points to targets where intervention may reduce these adverse outcomes.

Understanding heart failure; explaining telehealth - a hermeneutic systematic review

BACKGROUND

Enthusiasts for telehealth extol its potential for supporting heart failure management. But randomised trials have been slow to recruit and produced conflicting findings; real-world roll-out has been slow. We sought to inform policy by making sense of a complex literature on heart failure and its remote management.

METHODS

Through database searching and citation tracking, we identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta-analyses and 8 qualitative reviews); six mega-trials and over 60 additional relevant empirical studies and commentaries. We synthesised these using Boell's hermeneutic methodology for systematic review, which emphasises the quest for understanding.

RESULTS

Heart failure is a complex and serious condition with frequent co-morbidity and diverse manifestations including severe tiredness. Patients are often frightened, bewildered, socially isolated and variably able to self-manage. Remote monitoring technologies are many and varied; they create new forms of knowledge and new possibilities for care but require fundamental changes to clinical roles and service models and place substantial burdens on patients, carers and staff. The policy innovation of remote biomarker monitoring enabling timely adjustment of medication, mediated by "activated" patients, is based on a modernist vision of efficient, rational, technology-mediated and guideline-driven ("cold") care. It contrasts with relationship-based ("warm") care valued by some clinicians and by patients who are older, sicker and less technically savvy. Limited uptake of telehealth can be analysed in terms of key tensions: between tidy, "textbook" heart failure and the reality of multiple comorbidities; between basic and intensive telehealth; between activated, well-supported patients and vulnerable, unsupported ones; between "cold" and "warm" telehealth; and between fixed and agile care programmes.

CONCLUSION

The limited adoption of telehealth for heart failure has complex clinical, professional and institutional causes, which are unlikely to be elucidated by adding more randomised trials of technology-on versus technology-off to an already-crowded literature. An alternative approach is proposed, based on naturalistic study designs, application of social and organisational theory, and co-design of new service models based on socio-technical principles. Conventional systematic reviews (whose goal is synthesising data) can be usefully supplemented by hermeneutic reviews (whose goal is deepening understanding).

Let Us Talk About Moving: Reframing the Exercise and Physical Activity Discussion

Noncommunicable and chronic disease are interchangeable terms. According to the World Health Organization, "they are of long duration and generally slow progression. The 4 main types of chronic diseases are cardiovascular diseases (ie, heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes." We have known about the benefits of physical activity (PA) for thousands of years. Perhaps our approach, from public health messaging to the individual clinical encounter, as to how PA and exercise are discussed and prescribed can be improved upon, with the ultimate goal of increasing the likelihood that an individual moves more; ultimately moving more should be the goal. In fact, there is an incongruence between the evidence for the benefits of physical movement and how we message and integrate PA and exercise guidance into health care, if it is discussed at all. Specifically, evidence clearly indicates any migration away from the sedentary phenotype toward a movement phenotype is highly beneficial. As we necessarily move to a proactive, preventive healthcare model, we must reconceptualize how we evaluate and treat conditions that pose the greatest threat, namely chronic disease; there is a robust body of evidence supporting the premise of movement as medicine. The purpose of this perspective paper is to propose an alternate model for promoting, assessing, discussing, and prescribing physical movement.

Improving care for people with heart failure in Uganda: serial in-depth interviews with patients' and their health care professionals

BACKGROUND

The short prognosis of patients with advanced heart failure (HF) and the associated multidimensional distress as illustrated in literature from high income countries necessitates the integration of palliative care into the care of advanced HF patients to address these needs and improve their quality of life. These needs, which are subjective, have not been described from the patients' and health care professionals'(HPs) view point in the Ugandan setting, a low income country with a different socio-cultural context. This study aimed at bridging this gap in knowledge by eliciting patients' and HPs' views of HF patients' needs over the course of their illness to enable generalists, cardiologists and palliative care clinicians to develop guidelines to provide patient-centred realistic care in Uganda.

METHODS

Serial qualitative in-depth interviews were conducted with HF patients who were purposively sampled and recruited in Mulago National Referral Hospital (MNRH) until thematic saturation. In-depth interviews were conducted at three time points with intervals of 3 month between interviews over the course of their illness in the hospital and their home context. One-off interviews were conducted with HPs that manage HF in MNRH. We used a grounded theory approach in data analysis. The Uganda National Council of science and technology approved the research.

RESULTS

Forty-eight interviews were conducted with 21 patients and their carers and eight interviews with their HPs. Multidimensional needs including physical, psychological, social, spiritual and information needs were identified. These highlighted the underpinning need to have normal functioning, control, to cope and adapt to a changed life and to find meaning. Spiritual needs were less recognised by HPs than the other multidimensional needs. Information needs were commonly unmet. Patients and HPs suggested improvements in care that were congruent with the recommendations in chronic disease care and the six pillars of the WHO health systems strengthening approach.

CONCLUSION

Management of HF in Uganda requires an approach that targets multidimensional needs, embraces multidisciplinary care and strengthens health systems which are all important tenets of palliative care.

Experiences of and Coping With Severe Aortic Stenosis Among Patients Waiting for Transcatheter Aortic Valve Implantation

BACKGROUND

Aortic stenosis (AS) is the most common valve disease in Western countries. Transcatheter aortic valve implantation (TAVI) has made it possible to treat patients with higher surgical risks. These patients are informed about their poor prognosis with only months or a few years to live without treatment. Because of their severe symptoms, limitations, and suffering, patients awaiting TAVI need special attention.

OBJECTIVE

The aim of this study is to describe patients' experiences of coping with severe AS and of waiting for TAVI.

METHODS

Swedish participants (n = 24; 9 women, 15 men) with a mean (SD) age of 80 (7.4) years who had been offered TAVI all agreed to participate in a presurgical interview. The interviews were recorded, transcribed verbatim, and analyzed using qualitative content analysis.

RESULTS

The participants' experiences of coping with AS and awaiting TAVI were described by the main theme "living on the edge, but trying to stay in control," which comprised 3 categories: "trying to cope with physical symptoms and anxiety," "trying to preserve self and self-esteem despite life-threatening illness," and "trying to process the decision to undergo TAVI."

CONCLUSIONS

Patients with AS and awaiting TAVI must cope with increasing symptoms and limitations in their social lives but still wish to be seen as the people they always have been. These patients may need extra support from healthcare personnel to process their experiences, which could help them to attach personal meaning to clinical information about the condition and its treatment that they could include in their decision about whether to undergo TAVI. Listening to patients' stories could help nurses and physicians to ensure that disease and treatment are meaningfully understood by the patient.

Living with cardiac resynchronization therapy: Challenges for people with heart failure

The number of people with heart failure requiring implantation of a cardiac resynchronization device is increasing in Iran. Although this intervention is an effective life-saving treatment, several challenges are associated with patients' lifestyle after insertion. This study identified the challenges and coping mechanisms of Iranians with heart failure living with cardiac resynchronization therapy. A qualitative approach using conventional content analysis was adopted. Seventeen people with heart failure and three nurses were recruited between December 2014 and November 2015 from a teaching hospital and a private clinic in Rasht, Iran. Participants were interviewed using semi-structured interviews lasting 30-60 min. Five themes emerged: (i) fear of implantation, (ii) the panic of receiving a shock from the device, (iii) lack of control over life, (iv) inadequacies of the healthcare system, and (v) psychosocial coping. A heightened understanding of these challenges and coping strategies could prepare healthcare professionals to provide better routine care, education, and support to the recipients of cardiac resynchronization therapy prior to implantation, during the recovery period, and for long-term management.

Experiences of long-term life-limiting conditions among patients and carers: what can we learn from a meta-review of systematic reviews of qualitative studies of chronic heart failure, chronic obstructive pulmonary disease and chronic kidney disease?

OBJECTIVES

To summarise and synthesise published qualitative studies to characterise factors that shape patient and caregiver experiences of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD).

DESIGN

Meta-review of qualitative systematic reviews and metasyntheses. Papers analysed using content analysis.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science were searched from January 2000 to April 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews and qualitative metasyntheses where the participants were patients, caregivers and which described experiences of care for CHF, COPD and CKD in primary and secondary care who were aged ≥18 years.

RESULTS

Searches identified 5420 articles, 53 of which met inclusion criteria. Reviews showed that patients' and caregivers' help seeking and decision-making were shaped by their degree of structural advantage (socioeconomic status, spatial location, health service quality); their degree of interactional advantage (cognitive advantage, affective state and interaction quality) and their degree of structural resilience (adaptation to adversity, competence in managing care and caregiver response to demands).

CONCLUSIONS

To the best of our knowledge, this is the first synthesis of qualitative systematic reviews in the field. An important outcome of this overview is an emphasis on what patients and caregivers value and on attributes of healthcare systems, relationships and practices that affect the distressing effects and consequences of pathophysiological deterioration in CHF, COPD and CKD. Interventions that seek to empower individual patients may have limited effectiveness for those who are most affected by the combined weight of structural, relational and practical disadvantage identified in this overview. We identify potential targets for interventions that could address these disadvantages.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42014014547.

What Is Known About the Benefits of Patient-Centered Care in Patients with Heart Failure

Treatment for chronic heart failure (CHF) has improved, and symptom burden has been identified as an important treatment goal. Because patient-centered care may ease the burden, we need to know its benefits for patients with CHF, hence this systematic literature review. We found that one benefit of person-centered care is an increase in quality of life in patients with CHF. Improvements were found in self-care, physical and mental status, health care costs, general uncertainty regarding illness and recovery, patient dignity, treatment, and systems of care. Improvements also were observed in symptom burden, self-efficacy, and quality of life. These findings indicate that person-centered care is a powerful approach to current and future health care. However, because an appropriate tool to measure person-centered care does not yet exist, it will be a challenge to determine whether the goal has been reached from a long-term and patient perspective.

Long-term effects of a dyadic psycho-educational intervention on caregiver burden and morbidity in partners of patients with heart failure: a randomized controlled trial

BACKGROUND

Partners of patients with heart failure provide both practical and emotional support. Many partners assume caregiving responsibilities without being aware of the burden related with this role.

OBJECTIVE

Our work has established that a psycho-educational intervention has benefits at 3, but not at 12 months for patients with heart failure. Further we had not described the long-term effects in caregivers. This study aimed to determine the 24-months effects of a dyadic psycho-educational intervention on caregiver burden and morbidity in partners of patients with heart failure and study factors associated with a change in caregiver burden.

DESIGN

A randomized controlled study design, with a follow-up assessment after 24 months.

SETTING AND PARTICIPANTS

Partners to patients with heart failure were recruited from two hospitals in the southeast of Sweden.

INTERVENTION

A three session nurse-led psycho-educational program was tested and included psychosocial support to maintain the partners' physical and mental functions, and perceived control. Several instrument were used to measure caregiver burden, perceived control, physical and mental health, depression and morbidity.

RESULTS

One hundred fifty-five partners were included. There were no significant differences in any index of caregiver burden or morbidity among the partners in the intervention and control groups after 24 months. Overall, the mean total caregiver burden was found to be significantly increased compared to baseline (36 ± 12 vs 38 ± 14, p < 0.05). A younger partner, less comorbidity, higher levels of perceived control, better physical health and less symptoms of depression in patients, and better mental health in the partners were factors associated with absence of increased caregiver burden over time.

DISCUSSION AND CONCLUSION

Our intervention did not significantly decrease caregiver burden or morbidity. Over time, several aspects of burden increased in both groups. To improve outcomes, individualized and targeted interventions might be beneficial. REGISTERED ON CLINICALTRIALS.

GOV IDENTIFIER

NCT02398799.

Use of the Late-Life Function and Disability Instrument for Measuring Physical Functioning in Patients With Heart Failure

BACKGROUND AND PURPOSE

We evaluated the psychometric properties of the functioning component of the Late-Life Function and Disability Instrument (LLFDI) in individuals with heart failure (HF).

METHODS

Factor analyses were used (N = 151) to assess the dimensionality and structure of the basic and advanced lower extremity function subscales. Rasch model scores were compared to the raw means of the items.

RESULTS

Rasch scores correlated with the raw means of the items at r = .96, indicating raw means are comparable to the more complicated Rasch analysis in estimating physical functioning using the basic and advanced subscales.

CONCLUSIONS

The lower extremity physical functioning subscales of the LLFDI have potential as a clinical assessment tool to identify HF patients who are at high risk for functional limitations.

Heart failure patients' experiences of mobile phone-based telemonitoring in self-care: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to explore heart failure patients' experiences of mobile-phone based telemonitoring in self-care.

Continuity means "preserving a consistent whole"--A grounded theory study

Living with a chronic disease like chronic heart failure (CHF) results in disruptions, losses, and setbacks in the participants' daily lives that affect health and well-being. By using grounded theory method, we illuminate whether persons with CHF experience discontinuity in life and, if so, what helps them to preserve and strengthen continuity in their daily lives. Thirteen individual interviews and one group interview with five participants, aged 62 to 88 years, were carried out. Through data collection and data analysis, we constructed three concepts that make up a model illustrating the participants' experiences in daily life in relation to corporeality, temporality, and identity: experiences of discontinuity, recapturing approaches, and reconciliation. The first concept, experiences of discontinuity, was constructed from the following categories: the alienated body, the disrupted time, and the threatened self. The second concept, recapturing approaches, consists of categories with continuity creative constructions: repossessing the body, maintaining a façade, seizing the day, restoring the balance of time, and preserving self. These actions are intended to overcome problems and master changes in order to maintain balance in daily life through constructions that recreate normality and predictability. The third concept, reconciliation, was constructed from three categories: feel normal, set to adjust, and be positioned. These categories describe how the participants minimize their experiences of discontinuity by recapturing approaches in order to reconcile with various changes and maintain continuity in daily life. Our findings provide a fresh perspective on continuity that may contribute to the development of significant interventions in continuity of care for persons with CHF. However, continuity requires that healthcare systems support each patient's ability to manage change, reorientation, and adjustment to the new situation in order to make it easier for the patient to create and continue living their daily lives as they desire.

Heart failure clients' encounters with professionals and self-rated ability to return to work

BACKGROUND

People with heart failure are sick listed for long periods and disability pension is common. Healthcare professionals need knowledge about factors that can enhance their return to work processes.

AIMS

This study focus on people on sick leave due to heart failure and their encounters with healthcare professionals/social insurance officers. Specifically, it aimed to investigate associations between: (1) encounters and socio-demographic factors and, (2) encounters and self-rated ability to return to work.

MATERIAL AND METHODS

A cross-sectional study based on registry data and a postal questionnaire to people on sick leave due to heart failure (n = 590). Bivariate correlation analyses and logistic regression analyses were used. Results Gender, income, and age were strongly associated with encounters with both social insurance officers and healthcare professionals. Self-rated ability to return to work was associated with the encounters 'Made reasonable demands', 'Gave clear and adequate information/advice' and 'Did not keep our agreements'.

CONCLUSION AND SIGNIFICANCE

To enhance clients' abilities to return to work demands should be reasonable, information and advice need to be clear, and agreements should be kept. These results can be used by healthcare professionals as occupational therapists involved in vocational rehabilitation for people on sick leave due to heart failure.

Eating for 1, Healthy and Active for 2; feasibility of delivering novel, compact training for midwives to build knowledge and confidence in giving nutrition, physical activity and weight management advice during pregnancy

Background

Women in Wales are more likely to be obese in pregnancy than in any other United Kingdom (UK) country. Midwives are ideally placed to explore nutrition, physical activity and weight management concerns however qualitative studies indicate they lack confidence in raising the sensitive issue of weight. Acknowledging this and the reality of finite time and resources, this study aimed to deliver compact training on nutrition, physical activity and weight management during pregnancy to increase the knowledge and confidence of midwives in this subject.

Methods

A compact training package for midwives was developed comprising of evidence based nutrition, physical activity and weight management guidance for pregnancy. Training was promoted via midwifery leads and delivered within the Health Board. Questionnaires based on statements from national public health guidance were used to assess changes in self-reported knowledge and confidence pre and post training. Descriptive statistics were applied and 95% confidence intervals were calculated.

Results

43 midwives registered for training, 32 (74%) attended and completed the questionnaires. Although, pre training knowledge and confidence varied between participants, statistically significant improvements in self-reported knowledge and confidence were observed post training. 97% indicated knowledge of pregnancy specific food and nutrition messages as ‘better’ (95% CI 85 to 100), as opposed to 3% stating ‘stayed the same’ – 60% stated ‘much better’. 83% indicated confidence to explain the risks of raised BMI in pregnancy was either ‘much’ or ‘somewhat better’ (95% CI 66 to 93), as opposed to 17% stating ‘stayed the same’. 89% indicated confidence to discuss eating habits and physical activity was ‘much’ or ‘somewhat better’ (95% CI 73 to 97) as opposed to 11% stating ‘stayed the same’. Emergent themes highlighted that training was positively received and relevant to midwifery practice.

Conclusions

This study provides early indications that a compact nutrition, physical activity and weight management training package improves midwives self-reported knowledge and confidence. Cascading training across the midwifery service in the Health Board and conducting further studies to elicit longer term impact on midwifery practice and patient outcomes are recommended.

Heart failure patients' attitudes, beliefs, expectations and experiences of self-management strategies: a qualitative synthesis

OBJECTIVES

To develop a model of heart failure patients' attitudes, beliefs, expectations, and experiences based on published qualitative research that could influence the development of self-management strategies.

METHODS

A synthesis of 19 qualitative research studies using the method of meta-ethnography.

RESULTS

This synthesis offers a conceptual model of the attitudes, beliefs, and expectations of patients with heart failure. Patients experienced a sense of disruption before developing a mental model of heart failure. Patients' reactions included becoming a strategic avoider, a selective denier, a well-intentioned manager, or an advanced self-manager. Patients responded by forming self-management strategies and finally assimilated the strategies into everyday life seeking to feel safe.

DISCUSSION

This conceptual model suggests that there are a range of interplaying factors that facilitate the process of developing self-management strategies. Interventions should take into account patients' concepts of heart failure and their subsequent reactions.

Congestive heart failure self-management among US veterans: The role of personal and professional advocates

OBJECTIVE

Understand patients' experiences with primary care services for congestive heart failure (CHF) and explore the relationship between health services and self-management.

METHODS

We conducted semi-structured interviews with thirty-nine patients with CHF receiving care at one Veterans Affairs Medical Center (VA). We analyzed data using thematic content analysis.

RESULTS

Participants acknowledged the importance of ongoing engagement in the plan of care for CHF. They attributed success in this effort to be greatly influenced by personal advocates. The advocates included both members of the healthcare team with whom they had a continuity relationship and friends or family members who assisted on a daily basis. Participants also identified psychological symptoms as a major barrier to carrying out self-care.

CONCLUSION

Patients identify relationships with health care workers, help from family and friends, and mental health problems as major influences on the ability to manage their CHF.

PRACTICE IMPLICATIONS

Efforts to optimize CHF self-management should attend to health system and psychosocial barriers to care.

Occupational performance and strategies for managing daily life among the elderly with heart failure

AIM

The aim of this study was to describe experiences of limitations in occupational performance and strategies for managing daily activities among the elderly with chronic heart failure (CHF).

METHODS

Ten participants from primary healthcare with a confirmed diagnosis of CHF were interviewed. The interviews were analysed using qualitative content analysis.

RESULTS

The first theme, "Redefining an active life, aware of one's impaired body", was based on four sub-themes: realizing one's limited activity ability; striving to preserve an active life; focusing on meaningful activities; and changing vs. not changing habits and roles. The second theme, "Planning activities and balancing the degree of effort", was based on three sub-themes: limiting, organizing, and rationalizing activities; adjusting activities to today's ability; and using technology and adapting the environment.

CONCLUSIONS

Elderly people with CHF are struggling with an ongoing process of occupational adaptation due to periodical physical decline and fluctuating day-to-day ability. This highlights a need for information on strategies from a holistic perspective and client-centred occupational therapy interventions.

Describing self-care in Italian adults with heart failure and identifying determinants of poor self-care

BACKGROUND

Self-care improves outcomes in patients with heart failure; however, no studies have been conducted on this topic in Italy.

AIMS

We aimed to describe self-care in Italian adults with heart failure and to identify sociodemographic and clinical determinants of self-care.

METHODS

A cross-sectional design was used to study 1192 heart failure patients enrolled across Italy. We measured self-care using the Self-Care of Heart Failure Index version 6.2, which measures self-care maintenance, management and confidence. Sociodemographic and clinical data were tested as potential determinants of self-care.

RESULTS

The mean age of the sample was 72 (SD = 11) years; 58% were male. In the three areas of self-care, scores ranged from 53.18 to 55.26 and few people were adequate in self-care (14.5% to 24.4% of the sample). Self-care behaviours particularly low in this population were symptom monitoring, exercise, use of reminders to take medicines and symptom recognition. Confidence in the ability to keep oneself free of symptoms and relieve symptoms was low. Taking fewer medications, poor cognition, older age, having a caregiver, being male and having heart failure for a shorter time predicted poor self-care maintenance. Poor cognition, not being employed, being male, and having worse New York Heart Association class predicted poor self-care management. Poor cognition, taking fewer mediations, older age, and male gender predicted poor self-care confidence.

CONCLUSION

Self-care is poor in Italian heart failure patients. Determinants of poor self-care identified in this study can help to target patients' education. Male gender and poor cognition were consistently associated with poor self-care maintenance, management and confidence.

Melatonin protects against ischemic heart failure in rats

Ischemic injury, which occurs as a result of sympathetic hyperactivity, plays an important role in heart failure. Melatonin is thought to have antiatherogenic, antioxidant, and vasodilatory effects. In this study, we investigated whether melatonin protects against ischemic heart failure (HF). In Wistar albino rats, HF was induced by left anterior descending (LAD) coronary artery ligation and rats were treated with either vehicle or melatonin (10 mg/kg) for 4 weeks. At the end of this period, echocardiographic measurements were recorded and the rats were decapitated to obtain plasma and cardiac tissue samples. Lactate dehydrogenase, creatine kinase, aspartate aminotransferase, alanine aminotransferase, and lysosomal enzymes (β-D-glucuronidase, β-galactosidase, β-D-N-acetyl-glucosaminidase, acid phosphatase, and cathepsin-D) were studied in plasma samples, while malondialdehyde and glutathione levels and Na+, K+-ATPase, caspase-3 and myeloperoxidase activities were determined in the cardiac samples. Sarco/endoplasmic reticulum calcium ATPase (SERCA) and caveolin-3 levels in cardiac tissues were evaluated using Western blot analyses. Furthermore, caveolin-3 levels were also determined by histological analyses. In the vehicle-treated HF group, cardiotoxicity resulted in decreased cardiac Na+, K+-ATPase and SERCA activities, GSH contents and caveolin-3 levels, while plasma LDH, CK, and lysosomal enzyme activities and cardiac MDA and Myeloperoxidase (MPO) activities were found to be increased. On the other hand, melatonin treatment reversed all the functional and biochemical changes. The present results demonstrate that Mel ameliorates ischemic heart failure in rats. These observations highlight that melatonin is a promising supplement for improving defense mechanisms in the heart against oxidative stress caused by heart failure.