Self-care Management in Heart Failure Using Roy Adaptation Theory-guided Intervention in the United Arab Emirates

Abstract

Purpose

To assess the knowledge and practice of self-care management among patients with heart failure (HF) after Roy adaptation theory-guided educational program.

Methodology

One group quasi-experimental pretest–posttest design of 30 purposively selected patients with HF was conducted. Outcomes were examined under three domains: knowledge, self-care maintenance, and monitoring pre- and post-intervention, using a validated instrument based on four adaptive modes of Roy's theory.

Major results

Most of the respondents were male (76.6%) and 56.7% were over 60 years of age. At the pretest, only 16.7% demonstrated adequate knowledge of self-care, and 76.7% reported poor practices in the domains of self-care maintenance and monitoring. Also, 90% scored poorly in self-care management. Knowledge of self-care practices increased at post-test (93.3%). There was a significant difference in knowledge (t = 15.79, df = 29, p < .001) and practice (t = 9.35, df = 29, p < .001) pre- and post-intervention. However, there was no significant association between selected demographic characteristics, knowledge, and self-care practice (p > .05).

Conclusion

Knowledge and practice of self-care management are poor among patients with HF. However, theory-driven practice can enhance care and patients’ quality of life.

Introduction

Heart failure (HF) is an international pandemic affecting at least 64.3 million people around the globe (James et al., 2018). A report from the American Heart Association predicted that the prevalence of HF would increase dramatically by 46% from 2012 to 2030 causing the loss of millions of dollars (Heidenreich et al., 2020). According to Benjamin et al. (2018), 6.5 million adult Americans have been diagnosed with HF, with an estimated prevalence of 2.5%. In the UAE, cardiovascular disease have been documented as the leading cause of death, with symptoms occurring a decade earlier than their counterparts in other developed nations (Shehab et al., 2022). Specifically for HF, AlHabeeb et al. reported in 2018 that 93,865 people were treated with a prevalence of 1% in the UAE (AlHabeeb et al., 2018).

Literature Review

Patients with HF develop exacerbating symptoms that may require frequent hospitalization. Zhao et al., (2021); and Wilkins et al. (2017) reported an inpatient admission rate as high as 48% in Europe. Despite the substantial advances in treatment for HF, the mortality and morbidity continue to be significantly higher. According to the INTER-CHF study, 16.5% of HF patients die within a year of diagnosis (Dokainish et al., 2016). Some authors reported a 40% of mortality rate to cardiovascular diseases, especially from ischemic heart disease and its complications (Bahit et al., 2018; Institute for Health Metrics and Evaluation, 2018).

HF not only affects the individual's functional capacity (Awotidebe et al., 2017) but also leads to impairment in activity of daily living (Van Nguyen et al., 2021). Effective self-care management strategies in HF can play an important role in promoting positive self-care behavior to alleviate the symptom severity, improve the Quality of Life (QOL), and delay the progression of the disease (Zhao et al., 2021). Therefore, adequate knowledge of self-care in HF is an essential element in maintaining the QOL (Riegel et al., 2016). However, Sedlar et al. (2017) and Lee et al. (2018) reported that 50% of patients with HF do not have a comprehensive understanding of signs, symptoms, and management, which directly correlates to poor self-care practices.

Accordingly, Riegel et al. (2016) emphasized that adequate knowledge is not the only predictor of effective self-care behavior, but also the skills to interpret relevant information and utilize readily available knowledge is another important component of effective action.

Educational programs tailored to empower patients with HF on self-care showed significant improvement in their knowledge and practice (Awoke et al., 2019; Koirala et al., 2018; Leavitt et al., 2020). Nursing theory-guided educational programs have strongly emerged as an effective strategy to provide comprehensive care to clients. Nursing theories like self-care theory (Riegel et al., 2016), social cognitive theory (Dessie et al., 2021), or normalization process theory (Herber et al., 2018) have all been used to improve the reliability, validity, and replicability of various studies. Nursing care based on theories or models pose a challenge to explore these areas and their findings in turn would strengthen evidence-based practice. The utilization of theories or models pertaining to specific disease conditions such as in HF for self-care management based on the Roy adaptation model (RAM) needs to be studied further in order to make it practically applicable in rendering holistic care to the patients. The goal of this study was to determine the effect of RAM-guided educational intervention on the self-care management of patients with HF. To the best of the researchers’ knowledge, there is a complete dearth of studies in the UAE on self-care management using RAM of patients with HF.

Conceptual Framework

Adaptation is the process and outcome of multiple control systems that are triggered by various stimuli, resulting in responses which are classified either as adaptive or maladaptive (Alligood, 2021). According to RAM, humans are adaptive systems that continuously interact and adapt to their environment in four modes: physiological, self-concept, role function, and interdependence. Stimuli include all external and internal circumstances that mutually affect the person's adaptation. According to this model, the nurse systematically examines the patient through health history and physical examination to identify the maladaptive behavior (nursing diagnoses/patient's problem) in the four dimensions, along with the stimulus of behavior (causes/related factors). Based on the findings a plan of care is designed which may require educational intervention to manage the maladaptive behaviors.

Within the context of HF, adaptation is an essential concept. Once the pumping function of the heart fails, the sympathetic nervous system, the renin-angiotensin-aldosterone system, and other systems are immediately activated in an attempt to maintain physiological integrity. Because HF is a clinical syndrome that affects the person as a whole, compensation is not limited to the biological aspect of the individual, but includes the psychosocial dimensions of the person's functioning. Unfortunately, compensatory mechanisms are not always effective in the long run. Therefore, an individual with HF gradually moves from an integral level of adaptation to compensatory and lastly to compromised adaptation as the disease progresses.

In the current study, self-care management is defined as purposeful and conscious adaptive behaviors resulting from the adaptation processes on the four physiological and psychosocial modes. Therefore, self-care practices such as daily weight monitoring or smoking cessation are effective adaptive behaviors that the patient can deliberately chose in order to maintain or restore a steady state. In this study, we focused on the perceptual and information processing component of the cognator system as explained in the RAM. The conceptual framework proposes that knowledge about self-care management is a major stimulus of self-care behavior. Other stimuli would be socio-demographic characteristics of patients with HF such as age, gender, ethnicity, level of education, social status, and comorbidities.

According to Alligood (2021), nursing interventions usually occur by either increasing, decreasing, modifying, removing, or maintaining internal and external stimuli that affect adaptation. In this study, we proposed that correcting patients’ misconceptions regarding the management of HF, and providing appropriate information (educational intervention), would result in perceptual modulation and information processing, thereby enhancing the patient's ability to adopt effective self-care behavior. Furthermore, we hypothesize that a stimulus can directly alter adaptation and affect self-care management practices as an outcome of the process. For instance, if a patient understands the fluid allowance and its rationale, this could influence his/her adherence to fluid restriction measures. Therefore, we propose a nursing education program that targets the adaptive modes and the stimuli to promote self-care practices.

Methods

Design

This was a one-group quasi-experimental pre-test post-test design. Questionnaires were administered to participants before intervention and 1 week after discharge.

Setting

The study was conducted in a tertiary hospital, designated as the National Center for Excellence in Cardiology in Abu Dhabi. The hospital is composed of over 730-bed capacity. Patients who were admitted with a medical diagnosis of HF were included in the study. These patients were purposively selected based on their willingness to participate, ability to read and write either Arabic or English and having N-terminal pro b-type natriuretic peptide (NT-pro-BNP) level of >400 pg/ml.

However, patients with known psychiatric or cognitive impairments, cardiogenic shock (any circulation support drug or devices such as intra-aortic balloon pump/inotropes), those who could not independently perform basic self-care activities (checking and recording weight) were excluded.

Sample Size Determination

A total of 75 patients were screened on admission for inclusion in the study. Applying the Raosoft sample size software calculator (http://www.raosoft.com/samplesize.html), an estimated sample size of 50 patients was calculated, at 95% confidence interval, 5% error margin, and 80% power. At the beginning of the study, the researchers screened 75 patients in order to recruit eligible 50 participants. Forty (40) were excluded (those who could not speak English or Arabic: n = 25, bedridden: n = 6, HF diagnosis was not documented in the chart: n = 4; declined participation: n = 5). In all 35 patients were enrolled based on the inclusion criteria. By the end of the study, one patient was still on admission (not discharged), and we lost contact with four patients and only 30 participants completed the study and were followed up as shown in the recruitment flow chart (Appendix 2).

Data Collection Tools

HF Self-care Practice Assessment Questionnaire (HFSCPA-Q) adapted from Riegel et al. (2004) and Jaarsma et al. (2003) was used to measure self-care practices. The domains were generated according to the four adaptive modes as described in RAM. These modes were classified into three themes: Self-care maintenance, self-care monitoring, and self-care management. Additionally, a table of specifications was created in order to ensure that all items were relevant to the research question. Multiple interviews were conducted with cardiologists, cardiology nurses, clinical resource nurses as well as patients, and the findings were used to revise and organize the items in a suitable sequence.

The Heart Failure Self-care Knowledge Assessment Questionnaire (HFSCKA-Q) was adapted from the Dutch Heart Failure Knowledge Scale (Van der Wal et al., 2005). Many questions were either reviewed or deleted after discussion with patients and experts in order to align with the conceptual framework of the study as well as the socio-cultural considerations of the country. The knowledge questionnaire composed of two sections: (1) demographic data sheet and (2) HF self-care knowledge. The following domains were included after a review of international and local guidelines: general information about HF; maintaining a low sodium diet; monitoring fluid intake and weight daily; medication compliance; exercise and activity; smoking cessation strategies and symptom recognition and management; social support.

Validity and Reliability

An expert panel of six professionals (four nursing academics with PhD in medical surgical nursing and two cardiologists) revised the items for clarity, relevance, and completeness. A cover letter along with the instruments and the content validity forms were sent to all the experts. The content validity ratio (CVR) and content validity index (CVI) were generated for each item and they were either retained, modified, or eliminated based on recommendation. Item-content validity index (I-CVI) was computed and an item was considered appropriate if the I-CVI was higher than 0.79 whereas, items between 70% and 79% were revised. However, questions with I-CVI value < 70%, or CVR < 0.49 were eliminated.

The Arabic version for both instruments was translated to English using a back-translation by two independent translators. Reliability was performed using 10 patients who were not included in the study. Cronbach alpha score (HFSCKA-Q) was 0.655 which is similar to DHFS (0.62) (Van der Wal et al., 2005). The computed Cronbach alpha of HFSCPA-Q was 0.88.

Scoring the Tools

The HFSCKA-Q focused on self-care knowledge using 22 items in a multiple-choice question format. For each question, there were three response options, with only one correct option. Each correct option = 1, wrong option = 0. The range of scores were interpreted as 0 (no knowledge) and 22 (perfect knowledge). A cut-off point (75%) was taken as follows: adequate knowledge (≥75%) or poor knowledge (<75%).

On the other hand, the HFSCPA-Q was a 5-point Likert scale to assess participants’ self-care behavior. Respondents were asked to indicate the degree to which they practiced self-care activities on the scale of 1–5 (1: never do it; 2: rarely do it; 3: sometimes do it; 4: often do it, and 5: always do it). The questionnaire consists of 25 positively-worded statements; thus, no reverse scoring was used. Example, “I check for shortness of breath with activity such as bathing and dressing.” On the 5-point scale, respondents who always perform the activity scored 5, those who often do it (4), those who sometimes do it (3), those who rarely do it (2), those who never do it (1). A total score was obtained by adding all individual items with a range of 25–125: the higher the score, the better the self-care behavior. A cut-off of 75% was taken and interpreted as follows: >75% (adequate self-care practice level), <75% (poor self-care practice level).

Ethical Considerations

Ethical approval was obtained from the institutional board number MAFREC-227. Each patient was approached upon admission and a detailed explanation was provided about all risks and benefits of participating in the study. Patients were encouraged to ask questions, following which clarifications were provided. In the end, the consent form was signed by the proposed participant. Code numbers were assigned to ensure confidentiality.

Recruitment of Participants

The prospective participants were referred to the primary investigator by the charge nurses or by daily review of admission records. Eligible participants were identified using the inclusion criteria during admission to the cardiac ICU or cardiology medical ward and those who met the research criteria were contacted by the primary investigator. The aim of the study and data collection procedure were clearly explained and those who were willing to participate provided written consent.

The Intervention (Self-Care Education)

The nursing process framework (Assessment, Planning, Intervention, and Evaluation) based on the RAM provided a theoretical guide for the intervention. A comprehensive nursing assessment (history) was obtained from each patient using the four adaptive modes of RAM as follows: physiological mode (signs and symptoms of HF decompensation, justifying needs for oxygenation, fluids, nutrition activity/rest, and protection). Self-concept, role function, and interdependence modes were simultaneously assessed through semi-structured questions by identifying beliefs about HF self-care management; perception about their ability to manage the impact of HF on their life roles; as well as exploring the ways which their support systems have been affected by HF. The stimuli were identified and educational goals were mutually set with the participants.

The intervention consisted of sessions of one-to-one self-care education. Each session lasted for 45–60 min according to a predefined educational plan, which emphasized stimuli recognition and modification. Each participant was provided with an instruction guide on self-care management behaviors such as exercises, diet restrictions, fluid intake, tobacco and alcohol intake, and so on. Participants were taught how to recognize, monitor, and manage their symptoms.

All participants were given time to ask questions and raise concerns at the end of the educational session. Each participant was followed up until discharge and evaluations were conducted 1 week after discharge.

Data Collection

Data were collected from 01/08/2021 to 16/09/2021. After gaining consent from the subjects, clinical and demographic data were gathered and the pre-test questionnaires were administered. This was followed by an individualized education session (within 48 h of admission) based on Roy's adaptation model. Due to the COVID pandemic situation, the post-test was administered 1 week after discharge through telephone calls.

Data Analysis

Descriptive statistics such as frequencies, mean, and standard deviation were used to analyze the demographic characteristics of the participants. Paired t-test was used to determine the effectiveness of the intervention within the group and a Chi-square test was used to infer association among variables. Respondents’ knowledge and practice of HF regarding self-care management were assessed. The cut-off score for knowledge (75%) was used to determine if patients have poor (<75%) or adequate (≥75%) knowledge level. Results are presented using tables and figures.

Results

Table A1 presents the demographic characteristics of respondents. Findings show that 76.7% of the study participants were male, also 56.7% were over 60 years of age. Regarding the level of education, the majority were high school graduates while only 26.3% obtained a university level of education, 43% were still engaged in different jobs, and 26.5% were already retired. Figure A1 shows clinical characteristics and comorbidity patterns, indicating that 66.6% had diabetes, and 56.7% had kidney-related problems. While atrial fibrillation and high blood pressure were reported among 40% of the study sample, 53.3% had an ejection fraction of less than 40%.

Figure A2 shows the severity of HF experienced by the patients, using the New York Heart Association (NYHA) classification system. Findings show that the majority of the respondents (43.3%) were in functional Class II, 36.7% in Class III, and only 6.7% were in functional Class I. From Table A2, respondents’ knowledge on sodium restriction was poor at pretest (66.7%), yet 93% had adequate knowledge about smoking cessation at pretest. Respondents knowledge increased at posttest.

From Table A3, self-care behavior at the pretest was low among the study participants. Specifically, 76.7% scored low in the domain of self-care maintenance, 83.3% had poor self-care management. However, the number of patients who had adequate and poor knowledge were equally distributed (50%) for self-care monitoring. Table A4 shows that the respondents’ understanding of HF self-care improved dramatically from 60.3% (pre-test) to 88% at post-test. Similarly, the practice score also increased from 60.48% to 72.1% post-intervention. Paired t-test analysis was conducted to evaluate the effectiveness of the RAM-guided education program. There was a statistically significant difference in practice pre- and post-intervention (p < .001). Furthermore, there was no statistically significant association between selected demographic characteristics (gender, age, religion, ethnicity) with knowledge and self-care practices; p > .05 (Table A5).

Discussion of Findings

The goal of the study was to examine the knowledge and practice regarding self-care management of patients with HF pre- and post-RAM-guided educational intervention. Findings indicated that the majority of the patients (83.3%) possessed poor knowledge and practice at the pretest. This finding is consistent with Ng'ang’a-Oginga (2016) in Kenya who reported that 89% (n = 288) had inadequate knowledge and suboptimal level of self-care in HF. In another study in Iran, Nomali et al. (2019) noted that 50% (n = 190) of their study population demonstrated poor knowledge of HF. Similarly, in Ethiopia, Hailu Gebru et al. (2020) revealed a poor self-care behavior rate of 45.8% among Ethiopian patients. The suboptimal level of self-care knowledge and practice among our study participants may be attributed to several factors including demographic variables. Previous studies revealed that younger adults aged between 18 and 27 years are more likely to obtain higher scores in self-care (Hailu Gebru et al., 2020). Participants in our study were over 35 years old. Furthermore, Tawalbeh et al. (2017) explained that limited access to HF rehabilitation centers for individualized HF education could be associated with poor self-care behavior knowledge and practice. This may proffer explanation to our findings as more than 70% of subjects did not have access to health insurance, thereby limiting their access to HF out-patient clinics. Another possible explanation for low self-care knowledge and practice in this study might be the absence of advanced practice registered nurses with HF specialization in the study setting; who could tailor the educational program to HF patients’ specific needs (Ordóñez-Piedra, 2021).

Educational intervention based on RAM had a positive effect as the self-care behavior of patients with HF improved post-intervention. Findings showed that knowledge and practice level were significantly enhanced from 60.3% to 88% and 60.48% to 72.1%, respectively. There was a significant statistical difference in both knowledge (p < .001) and practice (p < .001) pre- and post-intervention. However, we found no statistical association between self-care knowledge level and demographic (p > .05). In reference to age, our study findings are at variance with Hailu Gebru et al. (2020), Koirala et al. (2018), and Tawalbeh et al. (2017) who speculated that younger adult were more likely to have better self-care than the elderly. A possible explanation could relate to the physiological and cognitive decline in older adults. Additionally, in contrast to our findings, Koirala et al. (2018) observed that co-morbidities such as kidney diseases and diabetes could be associated with low level of self-care among HF patients. In this study, a single and strong determinant of self-care behavior is knowledge (p < .001). According to our findings, as patients’ understanding of principles of self-care in HF expands, their behavior improved accordingly. Consistent with the present results, previous studies have demonstrated that patients who have adequate knowledge tend to exhibit good self-care behavior (Liu et al., 2014). However, Jaarsma and Strömberg (2019) and Vidán et al. (2019) argued that knowledge on its own is not enough to improve self-care behavior, especially when dealing with elderly patients.

The RAM in nursing is one of the most widely used conceptual frameworks for guiding research, nursing practice, and training (ShariatPanahi et al., 2020). In this study, we hypothesized that self-care practice is an adaptive behavior that manifests externally as a response to stimuli. From our findings, knowledge is a strong stimulus (p < .001). During the intervention, adaptive modes were assessed and knowledge (stimulus) was targeted through the educational session. Our findings suggest that by improving knowledge (stimuli) of self-care among patients with HF, self-care behavior (adaptive response) can be modified (p < .001). Furthermore, since behaviors can be adaptive or ineffective, self-care also can be described as adequate or poor. Hence, we found that 83.3% have poor knowledge levels (stimuli) and 86.7% had poor self-care behavior (ineffective behavior).

Strengths and Limitations

The results of this study support the evidence that RAM is an appropriate guide in planning self-care management for patients with HF. However, the study adopted a one-group pretest–posttest design, where the respondents were their own control group. Additionally, the sample size was small, the study was delimited to only one hospital, and over 75% of study population were males. Furthermore, the self-care management practices were as reported by the respondents and not observed by the researchers.

Implications to Practice

The findings of the study emphasize the effectiveness of utilizing Roy's adaptation model-based practice in the self-care management of patients with HF, suggesting that theory-guided nursing practice provides opportunity for nurses to articulate their contributions to patient care, while enhancing the quality of care which they provide to patients with HF. We therefore recommend that an educational protocol based on RAM can be utilized as a guide to train novice nurses in giving effective individualized self-care management programs to patients with HF.

Conclusion

Knowledge and practice of self-care management are poor among patients with HF. However, a nursing theory-driven educational intervention program effectively improved patients’ knowledge and practice, thereby enhancing self-management behavior.