Electronic Thesis and Dissertation Repository

Thesis Format

Monograph

Degree

Doctor of Philosophy

Program

Nursing

Supervisor

Smye, Victoria

Abstract

Background: Heart Failure (HF) hospitalizations and readmissions remain unacceptably high despite medical advances and, in spite of the education provided to HF patients regarding the signs of fluid accumulation, HF exacerbations persist. There is a gap between patients recognizing the signs of fluid accumulation and performing timely self-management activities to control it. Currently, there is no standardized approach for nurse-led health coaching to assist patients in HF symptom management oriented to self-care activities within a primary healthcare (PHC) setting. There is a need to better understand how self-care interventions can be delivered within a PHC practice, which health outcomes can be achieved, and what education and system changes are required as a foundation for tailored, person-centered care.

Methods: A prospective, non-randomized mixed methods cohort study was conducted to a) refine and further develop a novel nurse-led health coaching self-care management intervention involving a self-care guidebook with an activity of the Adjusted Diuretic Dosing (ADD) tool for people living with HF (Phase 1), and b) examine the feasibility, acceptability, and initial impacts of this nurse-led health coaching intervention from the perspectives of HF patients, their caregivers and nurses who offered the intervention using a PHC approach in PHC (Phase 2). In Phase 2, an interpretive description methodology was employed using in-depth interviews to explore the experiences of nurses who offered the intervention and patients and caregivers’ experiences who engaged in the intervention. Selected quantitative data were collected from the patients and caregivers using surveys comprised of self-reported measures of health-related Quality of Life (QoL) and Self-Care Behaviours, both pre-and post-intervention. These data were analyzed descriptively to provide a deeper contextual understanding of the qualitative data.

Results: In Phase 1, 10 nurses participated in refinement of the intervention. Only minor revisions were made to the self-care activity tool while providing a process for site readiness to conduct Phase 2. In Phase 2, 4 nurses and 5 patient/caregiver dyads participated in this feasibility study in 3 primary care settings. Nurses often were not working at their full scope of practice being primarily focused on tasks rather than actively incorporating health promoting or disease modifying interventions into their care; this being shaped by the organization of care within these settings. This study enhanced nursing practice in the care of persons living with HF through the standardization of a nurse-led health coaching intervention with tools to support self-care. Overall, patient participants had obtained a therapeutic relationship with their nurse that resulted in positive self-care behaviours; specifically, in the areas of self-care management and monitoring and improved QoL. Caregiver contributions increased in areas involving self-care maintenance and confidence without burden which was influenced by the nurse engagement involving moral encouragement, emotional support, and being an active partner through health education.

Conclusions: The findings of this study demonstrated a trend to patient improved self-care management skills and QoL when a nurse–led health coaching intervention was tailored to the patients’ needs. In addition, caregiver engagement was increased without burden. This intervention holds promise in the care of HF patients and there is a need to conduct this work with a larger cohort of people with HF. Future studies should explore the effects of adopting personalized, nurse-led health coaching for patients living with other chronic medical conditions. The results from this study have the potential to improve the quality and consistency of HF patient care with improved outcomes for persons living with HF.

Summary for Lay Audience

Heart Failure (HF) is caused by a weakened heart muscle that results in fatigue, difficulty breathing from fluid accumulation in the lungs, abdomen, legs or feet contributing to weight gain. Despite good medical therapy, this chronic condition has no cure. HF is the leading cause of prolonged hospitalization for the elderly in Canada, causing an increased financial burden to the health care system. It is important that the patient and their support person are well informed about HF management and strategies to stabilize this disease process so improved quality of life (QoL) can be achieved. Educational materials alone are not sufficient. Implementing strategies that promote self-care skills that are personalized to the patient’s needs are necessary. This study examined a nurse-led health coaching approach that was tailored or “personalized” to the patient and their support person by addressing any health challenges that may interfere in successful participation in HF self-care management. First, a review of all the scientific literature on this topic was completed. Second, nurses who work in family medical clinics were asked to provide feedback on a self-care management tool that was developed to help patients with HF better engage in self-care. Third, the tool was refined and used by nurses supporting patients with HF and their caregivers as part of a nurse-led health coaching approach. Next, patients with HF and their caregivers completed surveys before and after using this approach to assess whether there were changes in their QoL and self-care management behaviours, particularly self-care maintenance, self-care management/monitoring, and self-care confidence. Lastly, the nurses were interviewed to provide feedback about their experiences of using the health coaching approach when supporting patients living with HF, and the patient and their support person were interviewed separately to gather feedback about participating in this nurse-led health coaching approach that involved the self-care activity of adjusting the fluid (“water”) pill to manage their HF symptoms. The findings of the study showed that patients had improved self-care management skills when a nurse–led health coaching intervention was tailored to the patients’ needs and this approach also enabled nurses to practice to full scope. Future studies should be larger to explore the effects of adopting personalized, nurse-led health coaching for patients living with other chronic medical conditions. This type of research is important to promote nurse-led health coaching interventions with a self-care management activity that encourages patients and caregivers to be actively involved with their health care resulting in reduce HF symptoms while improving their QoL.

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