Running head: HEART FAILURE EDUCATION

Heart Failure Education in A VA Outpatient Clinic
Delivered as Part of a Multidisciplinary Heart Failure Management Team
Emily Spano
Arizona State University

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Abstract

There is an estimated 6.2 million people Americans over the age of 20 suffering from
Heart Failure (HF) (Bejamin et. al., 2019). It is essential that HF patients have sufficient
knowledge about the disease and self-management (Abbasi, Ghezeljeh, & Farahani, 2018; Dinh,
Bonner, Ramsbotham & Clark, 2018). Lack of self-management is largely to blame for many HF
exacerbations. Current evidence supports utilizing both verbal and written education with an
emphasis on self-care and education delivered in a group setting or individual setting showed
equal impact on self-care and HF knowledge ( Hoover, et. al., 2017; Ross et. al., 2015; Tawalbeh,
2018). An outpatient VA clinic located in a suburb of the large metropolitan identified there was
no consistency on how a HF patient was educated, managed, or tracked and the registered nurses
(RNs) lacked knowledge of HF. As a results of these findings this Evidence Based Project (EBP)
was implemented. RNs were educated on HF and completed a self-assessment questionnaire
evaluating their knowledge pre and post education. The RNs, as part of a multidisciplinary team,
educated HF patients on signs and symptoms of HF as well as on how to manage the disease.
Patients completed, the Kansas City Cardiomyopathy Questionnaire (KCCQ) to assess quality of
life and the Self Care Heart Failure Index (SCHFI) to assess knowledge of HF and selfmanagement skills. These questionnaires were completed initially and at 30 and 60 day intervals.
The RNs self-assessment of their knowledge and ability to educate patients increased in all areas.
The patient’s KCCQ and SCHFI score improved at 30 days and 60 days when compared to their
initial score. Larger EBPs are needed over a longer period of time to assess the impact on
hospital readmissions and same day clinic visits for HF exhibitions.
Keywords: Heart Failure, self-care, education, self-management

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Heart Failure Education in A VA Outpatient Clinic
Delivered as Part of a Multidisciplinary Heart Failure Management Team
Heart failure (HF) affects millions adults in the United States (U.S.), despite
advancements in the treatment, HF remains a significant health concern. Heart failure (HF) is a
progressive disease of the heart that often results from an impaired ejection fraction (EF). This
deceased pumping ability leads to HF patients experiencing symptoms such as dyspnea, fatigue,
fluid retention, activity intolerance and chest pain (Moon, Yim, & Jeon, 2018). As the disease
progresses patients often experience palpitations, epigastric pain and the inability to sleep lying
flat due to paroxysmal dyspnea. These symptoms can significantly affect a patients ability to
function and can lead to a reduced quality of life and frequent hospital admissions and
readmissions. Controlling the abnormal symptoms and decreasing exacerbations depends on
greatly on the patient’s ability to recognize symptoms, know how to react to these abnormal
symptoms, and follow provider recommendations.

In patients with HF active involvement and

self-management of the disease is necessary. Support and education by health care professionals
is needed to improve self-management strategies for patients (Dinh, Bonner, Ramsbotham &
Clark, 2018).
Background/Significance
Problem Statement
In the U.S. the lifetime risk of developing HF for adults 40 years of age and older is 20%,
with 650,000 new HF cases diagnosed annually (Yancy et. al., 2013). HF is a very costly disease,
the U.S. spends nearly 30.7 billion dollars each year, including cost of health care services,
medications and missed days of work (Heart Failure fact sheet, 2019). According the 2013 to
2016 National Health and Nutrition Examination Survey (NHANES) there is an estimated 6.2

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million people Americans over the age of 20 suffering from HF (Bejamin et. al., 2019). This
number is up from 2009 to 2012, at that time it was estimated there were 5.7 adults in the United
States (US) suffering from HF. Moreover the incidence of HF is expected to increase by 46%
from 2012 to 2030 resulting in >8 million adults 18 years and older experiencing HF. As the
population of the US is aging and the overall life expectancy is increasing the lifetime risk of
developing HF is high. It is estimated the lifetime risk for those 45 years to 95 years is at 20%45%. According to CDC.gov, HF deaths are 168 per 100,000 nationally. Locally, the state of
Arizona does slightly better than the national average with 122 per 100,000, and for Maricopa
County the rate is 110 per 100,000. Hospitalizations for Medicare beneficiaries admitted for HF
nationally is 34 per 1,000, for Arizona it is 22.6 per 1,000, and for Maricopa County it is 22 per
1,000.
Every ten years as part of national benchmarks and goals are developed aimed at
improving the health of all Americans. These objectives are science-based and encourage
collaboration across communities to empower individuals to make healthier lifestyle choices. A
goal of Healthy people 2020 was to decrease the incidence of hospitalizations for people
suffering from HF, these goals are revisited over the 10 year period and adjusted. The goal of
reducing heart failure hospitalizations is proposed to continue for Healthy People 2030
(Secretary’s Advisory Committee, n.d.). The CDC has provided funding to 22 state health
departments and five large city/county health departments to develop new and innovative
approaches utilizing evidence based strategies to prevent and manage heart disease. One such
area the CDC proposes recipients look at is implementing services that improve selfmanagement and lifestyle changes for those patients with hypertension, hyperlipidemia, and/or
who have had a cardiac event (State, Local and Tribal Programs, 2020).

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HF is the most common cause for readmissions of Medicare patients. In 2010 The
Affordable Care Act (ACC) created the Hospital Readmissions Reduction Program (HRRP),
requiring Centers for Medicare and Medicaid Services (CMS) to penalized hospitals with high
readmission rates (Chamberlain, Sond, Mahendraraj, Lau, & Siracuse, 2018). The 30-day
readmission rate for HF patients decreased from 25.1% in 2009 to 23.5% in 2013. This reduction
in admissions created a cost savings of about $200 million.
Purpose and Rational
HF is a progressive disease of the heart that often results from an impaired ejection
fraction (EF). This deceased pumping ability leads to HF patients experiencing symptoms such
as dyspnea, fatigue, fluid retention, activity intolerance and chest pain (Moon, Yim, & Jeon,
2018). As the disease progresses patients often experience palpitations, epigastric pain and the
inability to sleep lying flat due to paroxysmal dyspnea. These symptoms can significantly affect
a patients ability to function and can lead to a reduced quality of life and frequent hospital
admissions and readmissions. HF is a complex disease process and it is essential for HF patients
to have sufficient knowledge about the disease and self-management (Abbasi, Ghezeljeh, &
Farahani, 2018; Dinh, Bonner, Ramsbotham & Clark, 2018). Patients with HF have a greatly
reduced health related quality of life (HRQL), frequent hospital admissions, and early mortality
resulting in poor health outcomes and increased costs (Abbasi, Ghezeljeh, & Farahani, 2018;
Dickson et al., 2015; Hagglunded et. al., 2015; Musekamp et. al., 2017). Ineffective HF selfmanagement including failure to recognize symptoms and delayed reporting of symptoms
accounts for 70% of HF hospitalizations (Reeder, Ercole, Peek, & Smith, 2015).
Controlling the abnormal symptoms and decreasing exacerbations depends on greatly on
the patient’s ability to recognize symptoms, know how to react to these abnormal symptoms, and

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follow provider recommendations. These self-management strategies include; (a) taking
medications, (b) eating a low sodium diet, (c) daily exercise, (d) weight loss, (e) tracking of
symptoms, weight and blood pressure (BP) readings daily (Yancy et. al., 2013; Heart Failure fact
sheet, 2019). Therefor it is important to improve on patient’s knowledge of HF and selfmanagement ability.
The purpose of this paper is to review and describe effective strategies and interventions
in self-management of HF patients and report on an evidenced based HF educational program
utilized with HF patients in an out-patient Veterans Administration (VA) primary care clinic in
large metropolitan area of Arizona.
Internal Evidence
A VA Health Care System in a large metropolitan area was reporting significant
admission and readmission rates for the HF patients. The most recent data shows HF admission
of 122.4 patients per 1000 were admitted to this VA Medical Center. This is not reflective of all
patients within this VA system, as not all patients go to the VA Medical Center for treatment.
Many VA patients have private insurance in addition to VA coverage and opt to go a non-VA
hospital. This would make one think that the actual admission rate is higher. The only way a
provider is aware of the admission is if they are notified by the hospital or if the patient
schedules a post hospitalization follow up appointment. According to Medicare.gov, the VA
medical center is worse than the national average for rate of readmissions for HF patients. There
was not a specific percentage for the VA listed on Medicare.gov.
This VA Health Care System also includes many primary care clinics. At one of these
outpatient primary care VA clinics a pilot program working was HF patients was being
developed. It was identified that there was no consistency on how a HF patient was educated,

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managed, or tracked within this outpatient VA clinic located in a suburb of the large
metropolitan area previously mentioned. The nurse manager at this clinic stated that some of the
RNs did not have a full understanding HF and how to educate HF patients. They did not fully
understand the problems or issues this population of patients face and there was no standardized
or consistent education provided to the heart failure patients.
The population for this EBP project is specific to the VA population. However there are a
limited number of studies done on VA patients with HF. The findings of other studies conducted
on the adult HF population will be generalized to the VA patient.
PICOT Question
This inquiry has led to the clinically relevant PICOT question “In US Veterans with heart
failure (P) how does structured evidenced based heart failure education (I) as compared to usual
care (C) affect the patient’s knowledge of heart failure, knowledge of self-management and
quality of life (O) over two months (T).”
Evidence Synthesis
Search Strategy
An exhaustive literature search was used to address the PICOT question. Databases
searched for this literature review include PubMed, CINAHL, and PschInfo. The databases were
searched using a combination of the following key terms: heart failure, education, compliance,
self management, and knowledge. Filters applied to the search included publications from the last
five years (01/2014-02/2019), English language, and peer-reviewed articles.
The initial search of PubMed was completed using the key terms heart failure, education,
self-management, knowledge and handouts. This search was too narrowing and yielded zero
results. The term handouts was removed and a search utilizing the remaining key terms heart

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failure, education, self management, and knowledge. This search yielded a result of 84
publications. An additional search was conducted using the key terms heart failure, education
and compliance, which yielded 152 studies.
The CINHAL database was initially searched using the key terms heart failure, education
and self management. The search yielded a result of 81 publications. An additional search was
conducted using the following key terms heart failure, education and compliance. This search
yielded 93 articles.
The database PyschINFO was initially searched using the following key terms heart
failure and self management, which yielded 377 articles. The search was further refined by
adding in the key term education. With this additional key term, there were 53 articles that
resulted from the search. This search was further refined with the addition of a dash between the
words self and management, and resulted in 27 articles. Additionally, the key terms heart failure,
compliance and education was searched. There were only 20 articles that resulted from this
search.
After reviewing the articles, titles, and abstracts from these databases searches there were
107 articles identified as relevant studies. This was further refined to include only studies that
involved an educational intervention and/or impact on self-management. In addition, preference
was given to high levels of evidence such as randomized control trials (RCTs). With this
redefined criteria there were 18 studies identified. Ten final articles were chosen for the purpose
of this review, including randomized control trials and Quasi-experimental studies (Appendix
A).

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Critical Appraisal and Synthesis
The 10 studies included in this literature review were evaluated utilizing Melnyke and
Fineout-Overholt’s (2015) rapid critical appraisal. The 10 articles chosen where published within
the last five years as to ensure the most recent and relevant data. The studies ranged from level II
to level III evidence. Six of the 10 studies were level II evidence. These studies were randomized
control trials (RCT), one of those six was quasi-experimental (QE) RCT. The other four studies
were level III evidence and were comprised of QE utilizing various types of non-randomized
methods (Appendix B). Three of the 10 studies received funding however, the funding for the
three studies did not appear to come from a source that affected the validity of the study. No bias
was recognized for any of the 10 studies (Appendix A).
The mean age for participants in the studies ranges from age 55-77 years old and the
percentage of males range from 48-68%. The sample size for eight of the studies ranged from
38-127, there were two outliers out of the 10 studies with a sample size of 16 and 371 (Appendix
B). There was a broad ethnic representation across the studies and the studies were conducted in
a variety of countries (Appendix A). Six of the 10 studies were conducted in an out-patient
setting, the other four were conducted in a hospital setting. All but one of the studies utilized
either group or individualized verbal education class. The one study that did not utilize verbal
education used a tablet installed in the patient’s home to deliver the education. Five of the nine
studies which used verbal education also gave the patients written materials (Appendix B).
Self-care heart failure index (SCHFI) was used as one of the measurement tools in five of
the studies. Two studies used the European Heart Failure Self-care Behavior 9-item (EHFScB9).
The most common dependent variable measured was self-care behaviors of the participants, this

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was evaluated by seven out of the 10 studies. Quality of life, HF knowledge and readmissions
were each evaluated in three of the studies (Appendix B).
Conclusion from Evidence
Heart failure remains a significant health concern worldwide. Heart failure exacerbations
affect both the patient’s physical health as well as their quality of life. In the United States there
is a significant impact on the nation financially and is a burden on the health care system as a
whole. This literature review revealed the range on interventions being used to address HF.
While there are numerous interventions explored in the literature, this review demonstrated that
current evidence supports utilizing both verbal and written education with an emphasis on selfcare. Education delivered in a group setting or individual setting showed equal impact on selfcare and HF knowledge (Appendix B).
Theoretical Framework
The Situation-Specific Theory of Heart Failure Self-Care was chosen to guide this
Evidence Based Project (EBP) project. The original self-care theory was developed in 2008 and
was revised and updated by Riegel and colleagues in 2016. The revised model has three self-care
processes: (a) self-care maintenance, (b) symptom perception, and (c) self-care management
(Appendix C). This theoretical framework is specific to the HF population and addresses many
of the needs when caring for this population. Symptom perception was added to this revised
model as the previous model only included symptom recognition, which was theorized to initiate
self-care management. This was not effective because patients who do not recognize their
symptoms cannot respond to them. In this new model, symptom perception includes both
symptom monitoring and recognition.

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This theoretical framework provides a logical way to help patients understand and
navigate the complex diagnosis of HF and can be applied to this evidence-based project.
Evidence has demonstrated the need to improve self-care in HF patients, with the most effective
method being education. It was demonstrated that the HF self-care theoretical framework
utilizing maintenance, symptom perception, and management are essential to self-care. The
Situation-Specific Theory of Heart Failure Self-Care will be incorporated into an outpatient
primary care clinic to improve education delivery and increase self-care.
Implementation Framework
The Health Outcomes Institute’s Outcomes Management (OM) Model can be used in
interdisciplinary settings as guide to define outcomes, measurement methods, define evidence
based practices, educate and train healthcare providers on the new practice and measure the
impact associated with the new intervention (Melnyk & Fineout-Overholt, 2015). The OM model
is divided in to four distinct phases (Appendix D). Phase one identifies the clinical problem,
outcomes, and instruments and data sources. Phase two consists of a critical appraisal of the
evidence, synthesis and analysis of findings, identifying key stakeholders, and developing
methods to support the new standardization. Phase three involves education of the clinicians,
finalize process and outcomes measurements, implementing new practice change and begin data
collection. Finally phase four comprises data collection, statistical analysis, dissemination of
findings, and identifying opportunities for additional improvements.
For this EBP project the following occurred at each phase of the OM model. In phase one
the clinical problem were identified after meeting with key stakeholders at the Phoenix VA
Medical Center. At the initial meeting HF was identified as a strategic initiative for this VA
Healthcare System and a connection was made with the Nurse Manager, a key stakeholder at the

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VA primary care clinic. For Phase two an extensive literature review was conducted to identify
promising interventions. Education was identified as a gap in patient care at the VA clinic. There
was no standardized HF education being utilized by the healthcare providers. In phase three the
RNs at the VA clinic were educated on the HF and use of an evidenced based HF educational
tool. At this phase baseline data was collected to evaluate the effectiveness of the education
provided. RNs will be educating HF patients and the HF patients will be given questionnaires
prior to receiving the HF education, 30 days and 60 days after receiving the HF education. Phase
four is the final phase during this phase pre and post data collection was closed. Statistical
analysis of the data was conducted to assess the effectiveness of the new practice change. In
addition there was dissemination of results to key stakeholders.
Project Methods
Arizona State University Institutional Review Board (IRB) approval and non-research
designation form the VA were obtained prior to implementation of the project (Appendix E). The
project was conducted at a VA outpatient clinic in Arizona as part of newly formed pilot
program consisting of a multidisciplinary heart failure management team. The nurse manager,
medical director, and RNs were the key stakeholders involved in this EBP project. The nurse
manager and medical director were essential in facilitating the engagement of the RNs. The
newly formed HF management team is a pilot program addressing the needs of stage 1 and stage
2 HF patients. The team consists of a MD, RN, a pharmacist, dietician, and a social work.
Education and training for the RNs occurred at a monthly staff meeting and an additional
education day was arranged for those who were not able to attend the staff meeting. The RNs
were educated on HF via a power point presentation, use of the Krames Patient Education:
Understanding Heart Failure educational booklet, the Green Light to Go form and daily symptom

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and weight tracking chart (Appendix F). After receiving the education the RNs signed a consent
and completed an optional self-assessment questionnaire evaluating their knowledge prior to and
after receiving the training (Appendix G).
A rolling enrolment was used, the patients were enrolled over a period of two months.
Completion of the final 60 day follow up survey of the final patients enrolled was to occur
approximately four months after initiation of patient education. The patients met with the RN
and were given the consent, demographics questionnaire, the two pre-surveys, the Self-Care of
Heart Failure Index v7.2 (SCHFI v7.2) and the Kansas City Cardiomyopathy Questionnaire
(KCCQ-12) (Appendix H). The patient then was given an educational packet including the
Krames HF booklet, the Green Light to Go form and the daily symptom and weight tracking
chart. The patients were educated by the RN utilizing these materials. Next the patient met with
each of the four disciplines. A follow up phone call from the RN occurred approximately at one
month and two months later. The 30 and 60 day follow up questionnaires were completed as part
of this phone call.
Two assessments were used to evaluate the outcomes. One was a self-evaluation by the
RNs assessing their skills, attitudes, and comfort prior to the education and training and after
receiving the education and training. As previously mentioned two different tools were utilized
with patients, the SCHFI v.7.2 and the KCCQ. Self-care is defined as a decision-making process
involving the choice of behaviors to maintain physical stability and the response to symptoms
when they occur (Riegel et al., 2009). The SCHFI v.7.2 measures self-care and is divided into
three sections, maintenance, management and confidence. Reigel and colleagues suggest scoring
each individually rather than as a total score. The KCCQ-12 was developed from the 23-item
Kansas City Cardiomyopathy Questionnaire (KCCQ) to be more feasible to implement (Spertus

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& Jones, 2015). It is used to evaluate HF disease impact on symptoms, function and quality of
life. The KCCQ-12 evaluates four areas; (a) physical limitation, (b) symptom frequency, (c)
quality of life, and (d) social limitation.
Data was collected as the project was implemented and was transcribed on to an excel
spreadsheet. At completion of the project the data was analyzed using Intellectus statistical
analysis software. No funding was received for this project. The budget for the project was
estimated to be at $4,476 (Appendix I). This included expenses for preparation, including hourly
expenses to design some of the tools and printing costs. Delivery expenses included education of
the RNs. Finally there will be costs during the evaluation phase to review and analyze data. In
addition to these direct costs, there are indirect cost including facilities, administrative costs, and
office supplies.
Results
Descriptive statistics was used when analyzing the data for both the RN self-assessment
and the patient’s questionnaires. There were approximately 15 RNs who attended the educational
session on HF and a total of nine RNs who answered the self-assessment questionnaire. The
average response increased for all questions when comparing the pre and post education
responses (Appendix J). The pre and post data was further analyzed using summary statistics
(Appendix J). Standard deviation (SD) measures the spread of data around the mean of a scale
variable (Intellectus, 2020). The SDs for the pre scores on average were greater than 1 and for
the post scores the SD was 0.53 for three of the questions and 0.87 for one questions which
indicates that there was a greater range of the scores for the pre questions when compared to the
post questions. The increase in scores indicates that the RNs self assessed to have increased
understanding of HF and an increased ability to educate HF patients.

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A total of 11 patients were enrolled, four patients completed the 30 days follow up
questionnaires and two completed the 60 day follow up questionnaire. All the patients enrolled
were male, age range was 45 years to 88 years, seven Caucasian, three African American, and
one Hispanic. Overall the KCCQ score increased at 30 days but dropped slightly when
comparing the 30 day to the 60 day score (Appendix K). However the 60 day score still remained
higher than the initial score, a higher score is indicative of an improved rating. The SCHFI also
showed improvement when comparing the initial to the 30 and 60 day score (Appendix K). An
increase in score is the desired outcome. The increase in the KCCQ score indicates that patients
had an improved quality of life and the increase in the SCHFI score indicates that patients had
improved understanding of HF and improved ability to self-manage the disease. Both the RN
manager and the medical director were very pleased with the results and supported continuing
the utilization of the tools and ensuring all RNs treating HF patients were educated on the disease
and how to educate patients. However the pilot HF clinic was being terminated. In addition the
RN manager, who was the champion for the project, has since retired. Not having this champion
and not having the HF clinic makes it difficult to sustain the education of the RNs on HF and
track patient data.
Discussion
The results of this DNP project demonstrated the impact that education can have on a HF
patients understanding of the disease. The results of this DNP project are consistent with findings
of studies on HF education. Tawalbeh (2018) study on cardiac education with HF patients
admitted to a hospital in Jordan demonstrated the impact that HF education had on the patients
knowledge and improvement in self-care behaviors. One of the goals of self-management of a
disease is to increase a patients skills and ability to manage a disease (Korzh & Krasnokutskiy,

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2016). The authors conducted their study with HF patients in a primary care clinic and found that
education plays a significant role in improving a patients health literacy and ability to selfmanage HF. As noted by Gonzaga (2018) HF education improved patients quality of life and
improved self-care management and confidence among HF patients. Furthermore Dinh and
colleagues (2019) demonstrated that education delivered by a nurse including individual
education using a HF booklet and teach back method showed marked improvement in
knowledge and self-care.
Despite being a small project this EBP project showed positive results and could be used
as foundation for a larger project involving more patients over a longer period of time.
Additional data could be tracked including the impact on hospitalizations and re-hospitalizations,
the need for same day appointments for HF exacerbations, medication compliance, and rate of
progression of the disease to worsening HF stages. There were several limitations encountered
when conducting this project. One major limitation was the restrictions on who was enrolled in
the pilot HF clinic, this limited the number patients involved in this EBP project. Another
limitation was the pilot HF clinic ended sooner than expected, this limited the number of 60 day
follow up responses that were able to be obtained. The ending of the pilot HF clinic also impacts
the likelihood of a more robust project occurring.
Conclusion
The literature review indicated that utilization of a both written and verbal education with
HF patients improved their ability to self-manage the disease and improved their quality of life
score. Helping HF patients better manage their disease benefits both the patients and the
healthcare system as a whole. Educating RNs on HF including the disease process and what
information is essential to educate HF patients, had a positive impact on the RNs knowledge of

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HF and on their ability to educate HF patients. Resulting in the HF patients having an improved
quality of life and HF self-management ability. This further validates the positive impact that
education has on the HF patient. The heart is the lifeline to our body and knowledge gives us the
power to live heart healthy lives.

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References

Abbasi, A., Ghezeljeh, T. N., & Farahani, M. A. (2018). Effect of the self-management
education program on the quality of life in people with chronic heart failure: a
randomized controlled trial. Electronic Physician, 10(7), 7028–7037. DOI:
10.19082/7028
Benjamin, E. J, Muntner, P. S., Alonso, A. W., Bittencourt, M. P., Callaway, C. M., Carson, A.
R., . . . Virani, S. S. (2019). Heart Disease and Stroke Statistics—2019 Update: A Report
From the American Heart Association. Circulation, 139(10), E56-E66. DOI:
10.1161/CIR.0000000000000659
Chamberlain, R., Sond, J., Lau, C., & Siracuse, B. (2018). Determining 30-day readmission risk
for heart failure patients: The Readmission After Heart Failure scale. International
Journal of General Medicine, 11, 127-141. DOI:10.2147/IJGM.S150676
DelaCruz, F., Quinn, Patricia, & Renold, Lowell. (2015). The impact of a one-on-one coaching
session on heart failure patients’ knowledge of self-care disease management, ProQuest
Dissertations and Theses.
Dickson, V., Melkus, G., Katz, S., Levine-Wong, A., Dillworth, J., Cleland, C., & Riegel, B.
(2014). Building skill in heart failure self-care among community dwelling older adults:
Results of a pilot study. Patient Education and Counseling, 96(2), 188-196. DOI:
10.1016/j.pec.2014.04.018
Dickson, V. V., Melkus, G. D., Dorsen, C., Katz, S., & Riegel, B. (2015). Improving heart failure
self-care through a community-based skill-building intervention: A study protocol. The
Journal of Cardiovascular Nursing, 30(4 Suppl 1), S14-24. DOI:
10.1097/JCN.0000000000000161

HEART FAILURE EDUCATION

19

Dinh, H., Bonner, A., Ramsbotham, J., & Clark, R. (2018). Self-management intervention using
teach-back for people with heart failure in Vietnam: A cluster randomized controlled trial
protocol. Nursing & Health Sciences, 20(4), 458–463. https://doi.org/10.1111/nhs.12534
Dinh, H., Bonner, A., Ramsbotham, J., & Clark, R. (2019). Cluster randomized controlled trial
testing the effectiveness of a self‐management intervention using the teach‐back
method for people with heart failure. Nursing & Health Sciences, 21(4), 436-444.
Gonzaga, M. (2018). Enhanced patient-centered educational program for HF self-care
management in sub-acute settings. Applied Nursing Research, 42, 22-34. DOI:
10.1016/j.apnr.2018.03.010
Hägglund, E., Lyngå, P., Frie, F., Ullman, B., Persson, H., Melin, M., & Hagerman, I. (2015).
Patient-centred home-based management of heart failure. Findings from a randomized
clinical trial evaluating a tablet computer for self-care, quality of life and effects on
knowledge. Scandinavian Cardiovascular Journal: SCJ, 49(4), 193–199. DOI:
10.3109/14017431.2015.1035319
Heart Failure Fact Sheet|Data & Statistics|DHDSP|CDC. (2019, January 08). Retrieved February
2, 2019, from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm
Hoover, C., Plamann, J., & Beckel, J. (2017). Outcomes of an interdisciplinary transitional care
quality improvement project on self-management and health care use in patients with
heart failure. Journal of Gerontological Nursing, 43(1), 23–31. DOI: 10.3928/0098913420160901-01
Intellectus Statistics [Online computer software]. (2020). Intellectus Statistics.
https://analyze.intellectusstatistics.com/

HEART FAILURE EDUCATION

20

Interactive Atlas of Heart Disease and Stroke. (n.d.). Retrieved January 2, 2019, from
https://nccd.cdc.gov/DHDSPAtlas/Default.aspx?state=AZ
Interactive Atlas of Heart Disease and Stroke. (n.d.). Retrieved January 2, 2019, from
https://nccd.cdc.gov/DHDSPAtlas/Default.aspx?state=AZ
Korzh, O. & Krasnokutskiy. S. (2016). Significance of education and self-management support
for patients with chronic heart failure in family physician practice. Family Medicine &
Primary Care Review, 18(4), 432-436. DOI: 10.5114/fmpcr.2016.63697
Mangla, A., Doukky, R., Powell, L. H., Avery, E., Richardson, D., & Calvin, J. E. (2014).
Congestive heart failure adherence redesign trial: a pilot study. BMJ Open, 4(12),
e006542. DOI: 10.1136/bmjopen-2014-006542
Mathews, S. (2018). Utilization of a Nurse-Guided Structured Teaching Plan to Reduce
Congestive Heart Failure (D.N.P.). Wilmington University (Delaware), United States -Delaware. Retrieved
from https://search.proquest.com/docview/2037164048/abstract/4E779CCD604C43B1P
Q/1
Mclaughlin, D., Hoy, L., & Glackin, M. (2015). Heart failure nurse specialist crisis interventions
and avoided hospital admissions. British Journal of Cardiac Nursing, 10(7), 326-333.
DOI: 10.12968/bjca.2015.10.7.326
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare:
A guide to best practice (Third ed.).
Moon, M. K., Yim, J., & Jeon, M. Y. (2018). The effect of a telephone-based self-management
program led by nurses on self-care behavior, biological index for cardiac cunction, and

HEART FAILURE EDUCATION

21

depression in ambulatory heart failure patients. Asian Nursing Research, 12(4), 251-257.
DOI: 10.1016/j.anr.2018.10.001
Musekamp, G., Schuler, M., Seekatz, B., Bengel, J., Faller, H., & Meng, K. (2017). Does
improvement in self-management skills predict improvement in quality of life and
depressive symptoms? A prospective study in patients with heart failure up to one year
after self-management education. BMC Cardiovascular Disorders, 17(1), 51. DOI:
10.1186/s12872-017-0486-5
Pope, C. A., Davis, B. H., Wine, L., Nemeth, L. S., Haddock, K. S., Hartney, T., & Axon, R. N.
(2018). Perceptions of U.S. Veterans Affairs and community healthcare providers
regarding cross-system care for heart failure. Chronic Illness, 14(4), 283–296. DOI:
10.1177/1742395317729887
Reeder, K. M., Ercole, P. M., Peek, G. M., & Smith, C. E. (2015). Symptom perceptions and selfcare behaviors in patients who self-manage heart failure. The Journal of Cardiovascular
Nursing, 30(1), E1-7. DOI: 10.1097/JCN.0000000000000117
Riegel, B. V., Dickson, V. M., & Faulkner, K. (2016). The Situation-Specific Theory of Heart
Failure Self-Care: Revised and Updated. The Journal of Cardiovascular Nursing, 31(3),
226-235. DOI: 10.1097/JCN.0000000000000244
Riegel, B. S., Lee, C., Dickson, V., & Carlson, B. (2009). An Update on the Self-care of Heart
Failure Index. The Journal of Cardiovascular Nursing, 24(6), 485-497. DOI:
10.1097/JCN.0b013e3181b4baa0
Ross, A., Ohlsson, U., Blomberg, K., & Gustafsson, M. (2015). Evaluation of an intervention to
individualise patient education at a nurse‐led heart failure clinic: A mixed‐method
study. Journal of Clinical Nursing, 24(11-12), 1594-1602. DOI: 10.1111/jocn.12760

HEART FAILURE EDUCATION

22

Rosswurm, M., & Larrabee, J. (1999). A model for change to evidence-based practice. Image-the Journal of Nursing Scholarship., 31(4), 317-322.
Secretary’s Advisory Committee on National Health Promotion and Disease Prevention
Objectives for 2030. (n.d.). Retrieved February 23, 2020, from
https://www.healthypeople.gov/sites/default/files/Report 7_Reviewing Assessing Set of
HP2030 Objectives_Formatted EO_508_05.21.pdf
Spertus, J. A., & Jones, P. G. (2015). Development and Validation of a Short Version of the
Kansas City Cardiomyopathy Questionnaire. Circulation. Cardiovascular Quality and
Outcomes, 8(5), 469–476. https://doi.org/10.1161/CIRCOUTCOMES.115.001958
Tawalbeh, L. I. (2018). The Effect of Cardiac Education on Knowledge and Self-care Behaviors
Among Patients With Heart Failure. Dimensions of Critical Care Nursing, 37(2), 78–86.
doi: 10.1097/DCC.0000000000000285.
Yancy, C., Jessup, M., Bozkurt, B., Butler, J., Casey, D., Drazner, M., . . . Wilkoff, B. (2013).
2013 ACCF/AHA guideline for the management of heart failure: A report of the
American College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. Journal of the American College of Cardiology, 62(16), E147-E239.
DOI: 10.1016/j.jacc.2013.05.019
Young, L., Kupzyk, K., & Barnason, S. (2017). The impact of self-management knowledge and
support on the relationships among self-efficacy, patient activation, and self-management
in rural patients with heart failure. The Journal of Cardiovascular Nursing, 32(4), E1-E8.
DOI: 10.1097/JCN.0000000000000390

HEART FAILURE EDUCATION

23

Appendix A
Table 1
Evaluation Table
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Abbasi, A.,
Ghezeljeh, T.
N., & Farahani,
M. A. (2018).
Effect of the
selfmanagement
education
program on the
quality of life in
people with
chronic heart
failure: a
randomized
controlled trial.

Theory/concept
ual framework
was not
explicitly stated,
it can be
inferred that the
Self-care deficit
theory could
have guided the
researchers.

Design:
RCT

N = 60 F 31
(29)
CG: n = 30 F 11
(19)
IG: n = 30 F 20
(10)

IV: Three
sessions of SM
EDU with FU
phone call
monthly for
three months

Iranian heart
failure QOL
questionnaire

Kolmogorov
-Smirnov
test

p<0.05 was
statistically
significant

Independent
-samples ttest

QOL:
p<0.001

Country: Iran

Purpose: To
determine
the effect of
SM EDU
program on
QOL in
people with
HF.

Setting: A
teaching
hospital in an
urban area of
Iran
Demographics:
CG:
Marital status;
Married = 25
Single = 5

DV: Iranian
heart failure
QOL
questionnaire:
severity of
symptoms,
physical
limitations,
social
interference,
psychological
condition, self-

Pairedsamples ttest
Chi-square
& Fisher
exact
SPSS
software

Symptoms:
p=0.002
Effect size
0.5
Physical
limitations:
p=0.145
Effect size
.37

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: II
Strengths: low
risk, noninvasive
intervention
Weaknesses:
Small n; did not
look at
depression and
social support
Conclusion:
SM EDU with
FU in people
with HF
improves QOL

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION
Funding: The
authors
received
financial
support from
Iran University
Registry of
Clinicl Trials
for the research,
authorship,
and/or
publication of
the article.
Bias: None
recognized

24
HF class;
Class I = 17
Class II = 13
Mean EF
30.92+8.96
IG:
Marital status;
Married = 20
Single = 10
HF class;
Class I = 16
Class II = 14
Mean EF
28.77+6.85
Inclusion:
previously
diagnosed CHF;
stabilized in
terms of the
acute condition
of the disease;
no sensorycognitive
problems;
literate and able
to speak in
Farsi.
Exclusion: not
attending the
EDU session
Attrition: 0

efficacy and
knowledge,
and life
satisfaction

Social
inference:
p=0.01
Effect size
1.1
Psychologic
al condition:
p=0.013
Effect size
.94

Feasibility:
Recommended
for use in health
care systems to
improve QOL
and ensure
adherence to
treatment in
people with HF.

Selfefficacy and
knowledge:
p<0.001
Effect size
1.2
Life
satisfaction:
p=0.12
Effect size
.53

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

Citation

DelaCruz, F.,
Quinn, Patricia,
& Renold,
Lowell. (2015).
The impact of a
one-on-one
coaching
session on heart
failure patients’
knowledge of
self-care
disease
management
Country:
United States

Funding:
None
recognized

Bias: None
recognized

25

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Middle Range
Theory of SC of
Chronic Illness

Design:
Quasi
experimental
RCT
Purpose:
To evaluate
the impact
of a one-onone
coaching
session on
HF patients’
knowledge
of SC
disease
management
as compared
to those who
received the
usual care,
which is a
discharge
instruction
from the
doctor.

N= 39 F 14 (25)
CG: n= 21 F 8
(13)
IG: n= 18 F 6
(12)

IV: The
educational
tool Caring for
your Heart:
Living Well
with Heart
Failure.

SCHFI English
version 6.2

Descriptive
statistics
including
means and
standard
deviation.
Independent
t-test was
used to
compare the
means for
quantitative
variables
and Chisquare test
for
homogeneit
y between
groups

DV1:
CG scores
increased by
11% as IG
increased by
15%

Setting: A
cardiology
clinic
Demographics:
Majority of the
patient
population is of
Asian Pacific
Islander and
Hispanic
ethnicity
Mean age of
CG: 60
Mean Age IG:
62.4
Inclusion:
selected based
on the following
criteria: (a) male
and female

DV: SCHFI
English
version 6.2
DV1:
maintenance
score
DV2:
management
scale scores
DV3:
confidence
scores

DV2:
CG scores
increased by
10%
IG
increased by
50%

DV3:
CG scores
increased by
0.41%
IG scores
increased by
11.88%

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: III
Strengths:
Weaknesses:
Limited
availability due
to age criteria
and English
fluency.
One ethnicity
A type II error
was identified,
this could be
minimized with
a larger sample
size.
Conclusions:
One-on-one
couching affects
Pts knowledge
of SC
maintenance,
symptom
management
and improve

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

26
patients (from
45 to 75 years
old); (b) ability
to speak, write,
and understand
conversational
English; (c)
with
documented
diagnosis of HF;
(d) NYHA class
I-III symptoms,
and (e) having
an identified
primary care
provider or
cardiologist for
follow-up
appointments.
Exclusions:
Exclusion
criteria included
(a) documented
HF NYHA class
IV, (b) living in
a skilled nursing
or board and
care facility; and
(c) other comorbidities that
have a terminal
impact on the
patient’s health
status such as

self-confidence
in making
healthcare
decisions.
Feasibility:
The couching
was proven to
be effective and
could be utilized
in a primary
care or
cardiology
office setting.

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

27
end-stage
chronic kidney
disease,
advanced
cancer, and
cardiomyopathy

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Dickson, V.,
Melkus, G.,
Katz, S.,
Levine-Wong,
A., Dillworth,
J., Cleland, C.,
& Riegel, B.
(2014).
Building skill
in heart failure
self-care among
community
dwelling older
adults: Results
of a pilot study

Situationspecific theory
of HF self care

Design:
RCT

N = 75
CG: n = 37; F
18 (19)
IG: n = 38; F 22
(16)
Setting:
community
senior centers
Demographic:
CG
Black: 11
Hispanic: 12
White: 8
Other: 6
IG:
Black: 9
Hispanic: 12
White: 12
Other: 5

IV: group
education
focused on
four major
areas of the SC
process:
(1) medication
adherence, (2)
low-salt diet,
(3) symptom
monitoring,
and (4)
symptom
management

DV1: SCHFI
v6.2

Chi-square
and
independent
samples ttests
a mixed
model
(between
and within
subject)
analysis of
variance
(ANOVA)
was
conducted

DV1: IG vs
CG F(2,
47) = 3.42,
p = .041
Cohens f =
.38

Country:
United States

Purpose: To
test the
efficacy of a
communitybased skillbuilding
intervention
on HF SC,
knowledge
and healthrelated
quality of
life (HRQL)
at 1- and 3months

DV1: SC
maintenance
DV2: SCM

DV2: SCHFI
DV2: DHFKS
DV3: HRQL

Cohen’s f
was
calculated as

Intervention
Improved
DV2: F(2,
41) = 4.10,
p = .024
(partial eta
squared =
.17)
Chens f=
.38

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: II
Strengths: use
of a health
educator,
community
based, low risk,
non-invasive
intervention,
ethnic diversity
Weaknesses:
small sample
size, may not
reflect the
ethnic minority
and low socio
economic status
population at

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION
Funding:
funded by the
American Heart
Association
Clinical
Research
Program Grant
Bias: none
recognized

28

CG:
Married: 7
Widowed: 7
Divorced: 14
IG:
Married: 7
Widowed: 8
Divorced: 21
Inclusion:
diagnosis of
chronic HF for
at least 3
months, were
able to read and
speak either
English or
Spanish, over
age 55, living in
a setting where
they could
engage in self
care
Exclusion:
Cognitive
impairment,
Attrition:
IG=5 and the
CG= 8 was
inability to
contact
individuals for
follow up

DV3:
Knowledge
DV4: Quality
of life

a
standardized
index of
effect sizes
Analyses
were
conducted
using IBM
SPSS v.
21.0

DV3: There
was a
significant
interaction
effect, F(2,
53) = 8.00,
p = .001
(partial eta
squared =
.23)
Cohens f=
.54
DV4: There
was no
significant
difference
in HRQL
between the
IG and the
CG , F(1,
36) = 4.11,
p = .05 and
the overall
summary
score F(1,
36) = 4.66,
p = .04
No
significant
effect

large, lack of a
costeffectiveness
analysis
Conclusion:
The intervention
improved SC
management,
maintenance
and knowledge
of HF.
Feasibility:
implications for
the growing
population of
communitydwelling adults
with HF
because it
leverages
community
resources.
Utilization of
trained health
educators can be
carry out in
many settings

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

29

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Gonzaga, M.
(2018).
Enhanced
patient-centered
educational
program for HF
self-care
management in
sub-acute
settings.

Expanded
Chronic Care
Model

Design:
RCT

N= 16
IG: n= 5 F (9)

Purpose: To
evaluate the
effectiveness
of a patient
centered
educational
program on
SCM among
HF in a subacute
setting.

Setting: two
sub-acute units

IV: Patients
and or
caregivers
were educated
for 15 to 30
minutes on
knowledge
deficits
identified by
the SCHFI
tool.

SCHFI: SCM,
SC maintenance
& self
confidence

Descriptive
statistics
utilizing
SPSS and
Wilcoxon
matchedpaired
signed rank

DV1: SCM
mean score
improved
from pre
2.12 to post
2.7
R = 0.700,
p = < .001
DV2: SC
maintenanc
e showed
statistically
significant
improveme
nt between
pre and post
scores r =
0.456, p = <
.001
DV3: Selfconfidence
mean score
improved
from pre
2.46 to post
2.72 r =

Country:
United States
Funding: Non
recognized
Bias: Non
recognized

Demographic:
Researcher did
not mention the
demographics
Inclusion:
Primary or
secondary
diagnosis with
HF who were
admitted to one
of the two units.
English
speaking with a
plan to
discharge back
to their
community.
Exclusions: Pts
with active

DV1: SCM
score
DV2: SC
Maintenance
DV3: Self
Confidence

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: II
Strengths: low
risk, noninvasive
intervention
Weaknesses:
small sample
size, researcher
did not report
deport
demographics
Conclusions:
The results of
the study
demonstrated
improvement in
all three
categories
evaluated.
Feasibility:
This study has
implications on
educational

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

30
psychiatric
conditions or
illnesses and
vulnerable
populations.

Citation

Theory/
Conceptual
Framework

Design/
Method

Hägglund, E.,
Lyngå, P., Frie,
F., Ullman, B.,
Persson, H.,
Melin, M., &
Hagerman, I.
(2015). Patientcentered homebased
management of
heart failure.
Findings from a
randomized
clinical trial
evaluating a
tablet computer

Theory/concept
ual framework
was not
explicitly stated,
it can be
inferred that the
situationspecific theory
of HF self-care
could have
guided the
researchers.

Design:
prospective,
RCT
Purpose: To
evaluate if a
home
intervention
system
utilizing a
tablet
computer
connected to
the Pts scale
had an effect

Attrition: 6
3 were
readmitted to
hospital
3 were DC to
long term care.
Sample/ Setting

N= 72
CG: n= 40; F 12
(28)
IG: n= 32; F 11
(21)
Setting: Three
University
hospitals in
Stockholm,
Sweden.
Demographic:
CG:
Age 76 + 7
IG:

0.823, p = <
.001

interventions
aimed at
improving SCM
in HF patients.
It had a small
sample size but
can utilized as a
guide future
studies.

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: II

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

IV: Tablet
computer was
installed in the
IG home. 1)
actual day
weight, drug
dose and a
short
informative tip
on how to
improve living
with HF; 2) an
overview of
information
about the HF
disease and

Self-care was
measured with
EHFScB-9
KCCQ and
Swedish version
of the Health
Survey was used
to measure
HRQL

Student ’ s ttest for
independent
samples if
normally
distributed
or if not
Mann –
Whitney test
A p < 0.05
were
considered
statistically
significant

DV 1: SelfCare
improved
with a p <
0.05
DV2:
HRQL
improved
with a p <
0.05
DV3:
Adherence
was a
median of
88% DV4:
the

Adherence was
defined as ‘ the
number of days
that the patient
had interacted
with the system,

Strengths: low
risk, noninvasive
intervention

Weaknesses:
Ten Pts that
were in the
intervention
group withdrew.
There were
statistically
significant high

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION
for self-care,
quality of life
and effects on
knowledge
Country:
Sweden
Funding:
Swedish
National
Quality registry
of HF
Bias: Non
recognized

on SC
behavior.

31
Age 75 + 8
Inclusion:
hospitalized and
diagnosed for
HF with
reduced ejection
fraction
(HFrEF) and/or
HF with
preserved EF
(HFpEF)
according to
guidelines with
New York Heart
Association
(NYHA) class II
– IV, measured
at
randomization,
prior to
enrolment
Exclusions:
were other
serious
conditions with
a life
expectancy of
less than 6
months,
diagnosed
dementia or
cognitive

lifestyle
advice; 3)
graphical
representation
of variations in
weight,
medication and
well-being
over time; and
4) contact
details to
responsible
nurses and
doctors at the
HF center and
to persons
responsible for
technical
support.
DV1: SelfCare
DV2: HRQL
DV3:
Adherence
DV4: Diseasespecific
knowledge
DV5: HF
hospitalization

divided by the
number of days
equipped with
the system
DHFKS was
used to measure
knowledge of
HF and the
regimen

knowledge
in both
groups
increased
and
improved
with (11%)
and (8%)
for the IG
and CG,
respectively
(p
0.05)
DV5: A
total of 7
patients
were
hospitalized
in the IG
(22%) and
11 in the
CG (28%).

number of Afib
Pts in the IG.
The use of the
DHFKS seemed
to of limited the
results due to
the high scores
at baseline.
Conclusions:
Utilization of a
tablet computer
with home
intervention
system
improved selfcare and HRQL
and reduced
hospital days
Feasibility:
This study
demonstrated
that the
utilization of a
tablet computer
is a valuable
tool for
improving Pts
with HF
outcomes and
for improving
self-care.

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

32
impairment of
such severity as
it would make
the patient
unable to
understand
instructions
provided

Citation

Theory/
Conceptual
Framework

Design/
Method

Hoover, C.,
Plamann, J., &
Beckel, J.
(2017).
Outcomes of an
Interdisciplinar
y Transitional
Care Quality
Improvement
Project on SelfManagement
and Health Care
Use in Patients
With Heart
Failure.
Country:
United States

Donabedian’s
quality
assessment
model and the
Medical
Outcomes
Study
Framework,
self-care theory

Design:
quasiexperimental
comparative
descriptive
study
Purpose: To
compare
SM, RAR,
and cost in
patients who
received a
transitional
care
program
compared to
those who

Attrition: 10
Sample/ Setting

N = 66; F 51
(32)
CG: n = 36; F
17 (19)
IG: n = 30; F 15
(15)
Setting:
Midwestern
acute care
hospital
Demographic:
mean age
77.48, mean CC
3.63

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

IV1:
implementatio
n of an
evidence-based
HF order set
on admission
to the hospital
IV2:
pharmacist
medication
reconciliation
IV3: one-onone pharmacist
teaching,
IV4: a
provider visit
scheduled
within 10 days

SCHFI

SPSS
version 18.0.

DV1, DV2,
& DV3:
Used
SCHFI
IG scores
for
maintenanc
e (mean =
0.37, SD =
0.48, t[28] =
4.12, p =
0.008),
managemen
t (mean =
0.46, SD =
0.7, t[28] =
3.55, p =
0.001), and

Independent
t-tests
Pearson chisquare tests
Gain scores
were
computed
and
compared
between and
within
groups.

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: III
Strengths:
multidisciplinar
y approach, low
risk, noninvasive
intervention
Weaknesses:
convenience
sample,
moderate
sample size, and
loss to FU.
Conclusion:
There were few

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION
Funding: None
recognized
Bias: none
recognized

received the
routine
hospital DC
plan

33
90% white nonHispanic
62% NYHA
class 3b-4
IG: mean age
75.36, mean CC
3.93
Inclusion:
Admitting
diagnosis of HF
to one of the
medical units,
age 21 and
older, ability to
read and
understand
English, and
lived within a
30-mile radius
of the admitting
hospital.
Exclusion: new
diagnosis of HF,
younger than 21
years old,
significant
cognitive
impairment.
Attrition: Total
of five
participants two

of discharge
IV5: HF
education, and
a visit from a
RN TC prior to
discharge.
IV6: A home
visit from the
RN TC within
72 hours of
DC
IV7: three FU
phones calls
over three
months.
DV1:
medication
awareness and
SM
DV2:
developing a
personal health
record
DV3:
scheduling and
maintaining
appointments
with specialists
and primary
care providers
DV4: early
recognition of
signs and
symptoms of

confidence
(mean =
0.57, SD =
0.8, t[28] =
3.89, p =
0.001)
conditions.
CG
maintenanc
e (mean =
0.26, SD =
0.62,
t[30] = 2.38,
p = 0.02)
and
confidence
(mean =
0.4, SD =
0.7, t[30] =
3.24,
p = 0.03)
conditions
DV4: IG vs
CG (mean =
–0.11, SD =
1.71 versus
mean =
1.08, SD =
1.91; t[40] =
2.096, p =
0.04

all cause
readmissions to
the hospital 30
days after
discharge for
patients who
received
Coleman Care
Transitions
Intervention.
Costs savings
dues to
decreased
readmission
rates. Improved
SM in the IG.
Feasibility:
With the
increasing
numbers of
older adults
living at home
there is a need
for collaboration
between
pharmacists,
physicians,
nurse
specialists,
home care
nurses, and
patients.

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

34
from the CG
and three from
the IG were lost
to follow up

HF
exacerbation
DV5: all cause
readmission
rates

DV5: CG
vs IG (χ2
[1] = 11.77,
p < 0.001);
16 of 66
(24%)
versus 4 of
66 (6%)

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Korzh, O. &
Krasnokutskiy,
S. (2016).
Significance of
education and
selfmanagement
support for
patients with
chronic heart
failure in family
physician
practice.

Theory/concept
ual framework
was not
explicitly stated,
it can be
inferred that the
situationspecific theory
of HF self-care
could have
guided the
researchers.

Design:
RCT, Crosssectional
survey

N= 371
CG: n= 198
IG: n= 173

IV: HF
education
utilizing a 12hour program
entitled “Selfmanagement in
CHF.”
DV1: Dairy of
self control
DV2:
Monitoring of
BP is not less
than 1 time in
2 days
DV3:
Monitoring of
HR is not less

SECC-scale
assessment (the
scale of
evaluation of
clinical
condition in
CHF)
A questionnaire
was developed
asking a series
of questions
including basic
demographic
data, a series of
questions
regarding the
education
received, who

Microsoft
Office Excel
spreadsheet

DV1:
IG
Initial 17%
6 mo 88%

Country:
Ukraine

Purpose:
To ascertain
the sources
and content
of education
for patients
with CHF
and evaluate
the use of
patient
education
for selfmanagement

Setting:
Primary care in
the Ukraine
Demographic:
CG: average age
64 ± 8,4
IG: average age
63 ± 8,1
Inclusion: Pts
diagnosed with
New York Heart
Association

analyzed
using an
SPSS
statistical
package.
The
Kruskal–
Wallis test
was used to
examine the
difference in
knowledge
scores. The
chi-square

CG:
Initial 22%
6 mo 19%
DV2:
IG
Initial 22%
6 mo 87%
CG:
Initial 25%
6 mo 26%

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: II
Strengths:
low risk, noninvasive
intervention
Weaknesses:
Conclusions:
Results suggest
that the content
of selfmanagement
support for
patients with
CHF needs to
focus on

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION
Funding: None
recognized

Bias: None
recognized

support of
patients with
CHF in
primary
care.

35
class II or III
CHF, agreed to
education and
follow-up care
and would be
available by
phone.
Exclusions:
Patients who
experienced
significant
worsening of
their disease and
were transferred
to the intensive
care unit, were
hospitalized for
greater than 1
month, had a
chronic disease
other than CHF
or were
diagnosed with
a mental illness.

than 1 time in
2 days
DV4:
Measurement
of BM is 2
times per week
DV5:
Compliance
with the
recommendati
ons of
balanced diet
DV6:
Compliance
with the
recommendati
ons of daily
walks and
exercises

provided it and
self-perceived
knowledge.
Assessment of
SM needs was
assessed with 10
standardized
open-ended
questions.

test was
used to test
the
differences
in the
method of
CHF
diagnosis,
education
and support.

DV3:
IG
Initial 22%
6 mo 81%
CG:
Initial 25%
6 mo 34%
DV4:
IG
Initial 6%
6 mo 60%
CG:
Initial 5%
6 mo 5%
DV5:
IG
Initial 13%
6 mo 50%
CG:
Initial 12%
6 mo 19%
DV6:
IG
Initial 10%
6 mo 61%

addressing
patients’ needs
for improved
health literacy,
fears associated
with
uncertainty,
disease
progression and
suffering; and
expectations
about
overcoming or
replacing losses
and desire for
improved care.
Findings show
the significant
role of selfmanagement
and patient
education in the
treatment of
CHF
Feasibility:
Recommended
for use in
primary care
practices

CG
Initial 10%
Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

36
6 mo 20%

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Moon, M. K.,
Yim, J., &
Jeon, M. Y.
(2018). The
effect of a
telephone-based
selfmanagement
program led by
nurses on selfcare behavior,
biological index
for cardiac
cunction, and
depression in
ambulatory
heart failure
patients.

Theory/concept
ual framework
was not
explicitly stated,
it can be
inferred that the
situationspecific theory
of HF self-care
could have
guided the
researchers.

Design:
quasiexperiment
in
nonequivale
nt control
group design
Purpose: To
examine the
effects of a
telephonebased selfmanagement
support
program led
by nurses on
self-care
behavior,
biological
index for
cardiac
function,
and
depression

N= 38
CG: n= 8 F (12)
IG: n= 7 F (11)

IV: Telephone
selfmanagement
program

DV1: EHFScB9

Chi-square
test, Fisher's
exact test,
independent
-test, paired
t test, and
repeated
measures
analysis of
variance
using the
SPSS/WIN
21.0

DV1:
EHFScB9
t = 8.22, p
<.001

Country:
Korea
Funding:
None
recognized

Setting:
outpatient
department of
the Cardiology
Internal
Medicine
division of
Gyeongsang
National
University
Hospital located
in Jinju city
Demographic:
CG:
Age 60-64: 5
Age 65-69: 4
Age 70-75: 11
IG:
Age 60-64: 8

DV2:
NT-proBNP
levels

DV1: SCB
DV3: LV EF
DV2 & 3:
Cardiac
functional
index
DV3:
Depression

DV4: CES-D

DV2:
NT-proBNP
levels
t = -2.28, p
<.022
DV3: t =
2.24, p =
.032
DV4: CESD
t = -3.49, p
<.001

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: III
Strengths:
low risk, noninvasive
intervention

Weaknesses:
Short
intervention
period, did not
include patients
who could read,
did not involve
family
members, small
sample size,
bias might be
due to
utilization of
subjective
surveys
Conclusions:

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

Bias:
None
recognized

37
Age 65-69: 3
Age 70-75: 7
Inclusion:
age between 60
and 75 years,
heart failure
diagnosed for at
least 6 months
to less than 10
years by a
cardiologist, LV
EF of
Exclusions:
presence of
respiratory
diseases such as
chronic
obstructive
pulmonary
disease or
asthma,
diabetes,
chronic kidney
failure, stroke,
or terminal
cancer and prior
knowledge
about telephone
selfmanagement
programs for
heart failure.

A telephonebased selfmanagement
program
conducted by
nurses can
improve selfcare behaviors,
improve cardiac
function index
as indicated by
decreased NTproBNP levels
and increased
LV EF, and
reduce
depression in
patients with
heart failure.
Feasibility:
Recommended
for use in
outpatient
settings to
manage and
educate Pts with
HF.

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

38
patients who
could not read
the prescribed
booklets

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Ross, A.,
Ohlsson, U.,
Blomberg, K.,
& Gustafsson,
M. (2015).
Evaluation of
an intervention
to individualize
patient
education at a
nurse‐led
heart failure
clinic: A
mixed‐method
study.

Theory/concept
ual framework
was not
explicitly stated,
it can be
inferred that the
Middle Range
Theory of SC of
Chronic Illness
could have
guided the
researchers.

Design:
Mixedmethod
approach,
quasiexperimental
method

N= 85; 28 F
(57)
CG: n= 41; 12 F
(29)
IG: n= 44; 16 F
(28)

IV: Pts wrote
down
questions prior
to their visit
and received
standard EDU
as well as
personalized
EDU based on
their questions.

DV1: EQ sent to
the patients 7
days after visit.

Chi-square
test for
category
data

DV1: p
0.066 not
significant

Country:
Sweden
Funding: None
recognized

Purpose:
To evaluate
if addressing
patient
specific
questions of
patients with
HF could
individualiz
e education
and increase
patient
satisfaction.

Setting: HF
clinic
Demographic:
Age: 70; CG 68;
IG 71
Marital status:
Married: 53; CG
28; IG 25
Single: 32; CG
13; IG 19

DV1: Patients
perception of
involvement in
their education
DV2:
Satisfaction

Independent
t-test and
MannWhitney Utest
Significance
value was
set at 0.05

Question
“how it
could it into
daily life”
(p 0.027)
and “ I
received the
information
I wanted” (p
0.048)
Both IG and
CG showed
perception
of
empowerme
nt

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: III
Strengths:
Weaknesses:
Did not assess
why Pts did not
bring in
questions.
Conclusions:
Having Pts
write questions
ensure the
education is
personalized to
the patient.
The IG reported
high levels of
empowerment.
Feasibility:

Bias: None
recognized
Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

39
Inclusion: Pts
echo verified
HF, who came
to the clinic for
the first time.

Recommended
for use by
nurses in patient
education that
are looking for a
patient centered
approach.

Exclusion: Not
able to
communicate in
Swedish.

Citation

Theory/
Conceptual
Framework

Design/
Method

Tawalbeh, L. I.
(2018). The
Effect of
Cardiac
Education on
Knowledge and
Self-care
Behaviors
Among Patients
With Heart
Failure.
Country:
Jordan

A
theory/conceptu
al framework
was not
explicitly stated,
it can be
inferred that the
situationspecific theory
of HF self-care
could have
guided the
researchers

Design:
quasiexperiential
repeated
measure
convenience
sampling

Funding: None
recognized

Purpose:
to test the
effect of a
cardiac
educational
program on
knowledge
and SCBs

Attrition: 55
Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

N= 127; 55 F
(72)
CG: n= 65; 25
F (40)
IG: n= 62; 30 F
(32)

IV:
educational
program with
both verbal
and written
material

DV1: DHFS

Setting: a
governmental
hospital in an
outpatient
department

DV1: HF
knowledge test

G* power
was used
determine
the right
number of
participants
Power level
0.80, effect
size 0.25, a
level of .05

DV1:
statistically
significant
difference,
F3,113 =
66.06, P <
.001, in the
change of
knowledge
mean score
between the
pretest and
the second
posttest
based on the
groups

Demographic:
Mean age 55.52
CG:

DV2: SCHFI
DV3: number of
admissions

DV2: SCB
DV3: hospital
admissions

SPSS
version 22
SD

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
LOE: III
Strengths:
Highlighted the
importance of
education in
improving
knowledge and
SCBs among
patients with HF
in Jordan.
Weaknesses:
convenience
sampling
Limited to just
Jordan

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

Bias: None
recognized

among
patients with
HF in
Jordan

40
Working 41
Not working 24
Married 26
Unmarried 38
Illiterate 29
Educated 36
IG:
Working 41
Not working 21
Married 41
Unmarried 21
Illiterate 26
Educated 36
Inclusion:
included in the
study if they (a)
had HF proven
by signs and
symptoms and
chest x-ray
studies; (b) had
no mental or
cognitive
problems as
determined by a
physician; (c)
18 years and
older; (d)
willing to
participate; (e)
interviewed as
outpatients at

Short FU period
DV2:
statistically
significant
difference,
F3,113 =
78.14, P
<.001 in the
change of
managemen
t SCB mean
score
between the
pretest and
the second
posttest
based on the
groups
post hoc
showed a
statistically
significant
difference,
F1,113 =
67.15, P
<001, in the
change of
managemen
t SCB mean
score
between the
pretest and
the first
posttest

Conclusions:
Applying
cardiac
education
program helps
improve
knowledge and
self-care among
patients with
heart failure.
Feasibility:
Recommended
for use by
nurses educating
Pts on HF.
Should be
adopted in
clinical settings
to enhance
knowledge and
self-care
behaviors

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

41
the cardiac
clinic; and (f)
patients who
had not taken
part in a
previous
structured
educational
program
Exclusions:
unwillingness to
participate and
complaint of
life-threatening
conditions
involving
planned surgical
invasive
procedures
Attrition: 10

There was a
statistically
significant
difference,
F1,113 =
511, P =
.003, in the
change of
confidence
SCB mean
score
between the
first and
second
posttests
based on the
groups.
DV3:
control
group has
statistically
significant
higher
admission
rate, #2 1 =
4.57, P =
.03

Key: CC – comorbid conditions; CES-D - Center for Epidemiologic Studies-Depression Scale; CG – Control group; DC – discharge; DHFKS = Dutch HF
Knowledge Scale; DV-dependent variable; EDU – Education; EPB – Evidence Based Practice EF – Ejection fraction; EHFScB9 - European Heart Failure Selfcare Behavior 9-item; EQ – Empowerment Questionnaire; F – Female; FU – Follow up; HF – Heart failure; HL – health literacy; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; IG – Intervention group; IV- independent variable; LOE – Level of evidence; LV EF - left
ventricular ejection fraction M – Male; mo – months; N-number of studies; n- number of participants; NRS – Numeric Rating Scale; NYHA - New York Heart
Association; NT-proBNP – N-terminal pro-brain natriuretic peptide; Pt – Patient; SCB – self-care behavior; SCM – Self-care management; SD – standard
deviation; SM – Self-management; QOL – Quality of life; RCT – Randomized control trial; RAR – readmission rates; RN – registered nurse;; SC – Self-care;
SCHFI - Self-Care of Heart Failure Index; SPSS – Statistical Package for Social Sciences; TC - transition coach; UC – usual care

HEART FAILURE EDUCATION

42
Appendix B

Table 2
Synthesis Table
Author
Year
Level of
Evidence
Design

Setting
Received
Funding
Mean Age
Male (%)
Sample Size
Measurement
Tool

Abbasi et
al.
2018
II

DelaCruz
et al.
2015
II

Dickson et
al.
2014
II

Gonzaga et
al.
2018
II

Hägglund
et al.
2015
II

Hoover et
al.
2017
III

Korzh et
al.
2016
II

Moon et
al.
2018
III

Ross et al.

RCT

QE-RCT

RCT

RCT

Prospectiv
e, RCT

QE
comparativ
e
descriptive
study

RCT
Crosssectional
survey

QE in
nonequival
ent control
group

QE mixed
methods

QE
repeated
measure
convenienc
e sampling

OP

OP

OP

H
X

48.33
60
Iranian
heart
failure
QOLQ

OP

61.2
64.1
39
SCHFI

OP
X

46.66
75
SCHFI

Study Characteristics
H
H
X
Demographics
75.5
56.25
68.05
16
72
SCHFI
EHFScB9;
KCCQ;
DHFKS

H

77.48
48.48
66
SCHFI

OP

63.5
371
SECC-S

60.52
38
EHFScB9;
NTproBNP
levels;
LVEF;
CES-D

2014
III

70
67.05
85
EQ

Tawalbeh
et al.
2018
III

55.52
56.69
127
DHFKS;
SCHFI;
number of
hospital
admissions

Key: BP – blood pressure; CES-D - Center for Epidemiologic Studies-Depression Scale; DHFKS = Dutch HF Knowledge Scale; DV –
dependent variable; EDU – education; EHFScB9 - European Heart Failure Self-care Behavior 9-item; EQ – empowerment questionnaire; FU –
follow up; GE – group education; H – hospital; IE – individual education; IV – independent variable; HR – heart rate; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; NT-proBNP – N-terminal pro-brain natriuretic peptide; OP – out-patient; QE –
Quasi-experimental; QOLQ – quality of life questionnaire; HF – Heart failure; HL – health literacy; LVEF – left ventricular ejection fraction;
SC – self-care; SCC – self-care confidence; SCHFI – self-care heart failure index; SCM – self-care management; SECC-S – scale for evaluation
of clinical condition in hear failure; SM – self-management; V – verbal education; W – written educational material; Wt - weight; ↑ - increased; ↑
- decreased; ↔ - not statistically significant; * - statistically significant p-value < 0.050

HEART FAILURE EDUCATION

43
Interventions - IV

FU phone calls
IE or GE with V
or W

X
IE
V
W

IE
V
W

GE
V

IE
V

IE
W

X
IE
V
W

GE
V

X
IE
V
W

IE
V

GE
V
W

DV
Quality of life
Severity of
symptoms
Physical
limitations
SC

HF Knowledge
Readmission
Maintaining
appointments
Early
recognition of
symptoms
Monitoring BP
and HR
Compliance
Diary of self
control
CES-D
NT-proBNP
EQ

↔

*↑
*↓less
severe
*↑improve
d
*↑

*↑

*↑

↑

*↑

*↑

*↑
*↓

*↑ (SM &
SCC)
↑ (SCM)

*↑

*↑

*↑
*↓

*↓
*↑
*↑
↑
↑
↑
*↑
*↓
↔

Key: BP – blood pressure; CES-D - Center for Epidemiologic Studies-Depression Scale; DHFKS = Dutch HF Knowledge Scale; DV –
dependent variable; EDU – education; EHFScB9 - European Heart Failure Self-care Behavior 9-item; EQ – empowerment questionnaire; FU –
follow up; GE – group education; H – hospital; IE – individual education; IV – independent variable; HR – heart rate; HRQL - health-related quality
of life; KCCQ - Kansas City Cardiomyopathy Questionnaire; NT-proBNP – N-terminal pro-brain natriuretic peptide; OP – out-patient; QE –
Quasi-experimental; QOLQ – quality of life questionnaire; HF – Heart failure; HL – health literacy; LVEF – left ventricular ejection fraction;
SC – self-care; SCC – self-care confidence; SCHFI – self-care heart failure index; SCM – self-care management; SECC-S – scale for evaluation
of clinical condition in hear failure; SM – self-management; V – verbal education; W – written educational material; Wt - weight; ↑ - increased; ↑
- decreased; ↔ - not statistically significant; * - statistically significant p-value < 0.050

HEART FAILURE EDUCATION

44
Appendix C

Figure 1
The Situation-Specific Theory of Heart Failure Self-Care: Revised and Updated

HEART FAILURE EDUCATION

45
Appendix D

Figure 2
Outcomes Management Model

HEART FAILURE EDUCATION

46
Appendix E

IRB Approval

HEART FAILURE EDUCATION
Non-research designation form the VA

47

HEART FAILURE EDUCATION

48
Appendix F

Krames HF Education Booklet

Green Light to Go Handout

HEART FAILURE EDUCATION
Daily Symptom and Weight Tracking Chart

49

HEART FAILURE EDUCATION

50
Appendix G

RN Consent

HEART FAILURE EDUCATION
RN Knowledge Self-Assessment Questionnaire

51

HEART FAILURE EDUCATION

52
Appendix H

Patient Consent

HEART FAILURE EDUCATION
SCHFI v7,2

53

HEART FAILURE EDUCATION

54

HEART FAILURE EDUCATION
KCCQ

55

HEART FAILURE EDUCATION

56

HEART FAILURE EDUCATION

57
Appendix I

Budget
Phase
Preparation

Activities
Design tracking tool for
patients to monitor
weight and s/s
Print tracking tool for
patients to monitor
weight and s/s
Pay licensing fee for use
of KCCQ
Design RN SelfAssessment
questionnaire and
demographics form
Print Self-Assessment
questionnaire
demographics form,
KCCQ, and SCHFI
v.7.12
Design staff consent
form
Print staff consent form

Design patient consent
form
Print patient consent
form

Delivery

Order Krames HF book
and Green Light to Go
form, one for each staff
members as well as to be
given to patients
Create power point to be
utilized when educating
staff
Education of staff at staff
meetings
Attend staff meetings
during project timeline

Cost
*5hrs@$48

**90 for staff
& 50 for patients
140@$0.08***
*$115
*5hrs@$48

**90 for staff
& 50 for patients
140@$0.08***

*5hrs@$48

subtotal
$240

$11.20

$115
$240

$11.20

$240

**90 for staff
& 50 for patients
140@$0.08***
*5hrs@$48

$11.20

**90 for staff & 50
for patients
140@$0.08***
**90 for staff & 50
for patients
140@$4

$11.20

$240

$560

*5hrs@$48

$240

*10hrs@$48

$480

*25hrs@$48

$1200

HEART FAILURE EDUCATION

Evaluation
Total Direct
costs
Indirect costs

Total Costs
Direct and
Indirect

for reinforcement and to
answer questions
regarding new patient
education
Review and analysis of
results

58

*10hrs@48/hr

$480

$4,079.80
Including facilities,
telephone, maintenance
and repairs, clerical and
administrative costs, and
office supplies

Calculated based on
10% of total direct
costs

≈$4,476.00

$396.48

HEART FAILURE EDUCATION

59
Appendix J

Table 3
Profile Plot of RNs pre and post scores

Table 4
Summary Statistics for RNs pre and post scores

HEART FAILURE EDUCATION

60
Appendix K

Table 5
KCCQ average score, initial, 30 day and 60 day

Table 6
SCHFI average score, initial, 30 day and 60 day