Satisfaction of patients and caregivers with specialized nursing services for heart failure patients

http://doi.org/10.33698/NRF0277-Bandna Kumari, Sukhpal Kaur, Monika Dutta, Ajay Bahl, Parag Barwad

ABSTRACT

Background- Heart failure is a chronic cardiovascular disease posing signicant challenge to the healthcare professionals, patients and caregivers. Specialized nursing services through nurse led heart failure clinics are promising to enhance the satisfaction and thereby improving self-management of heart failure at home by the patients and caregivers. Aim– To assess the level of satisfaction of patients and caregivers with the specialized heart failure nursing services for management of heart failure. Material and methods- A prospective cohort study was conducted on patients suffering from heart failure and their caregivers attending outpatient department of PGIMER, Chandigarh, over a period of 2 months. They were given specialized heart failure nursing services. These services were comprised of a self-care instructional module comprising of individualized exercises, dietary precautions, assessment of their vital parameters and importance of adhering to therapeutic regimen like medications and follow ups etc. Twenty patients and their caregivers were assessed before and after 6 months of intervention. They were told to complete a questionnaire to rate their satisfaction with specialized nursing services on ve-point Likert scale. The questionnaire consisted of items like adequate knowledge of staff, ability to solve their queries, positive contribution in their lives etc. Results- Majority of the patients 15 (75%) as well as  caregivers 18 (90%) were highly satised with the nursing services. Only few patients 5 (25%) and caregivers 2 (10%) were moderately satised. None of the patients and caregivers was found in the category of fairly or not satised. Both the groups were similar in terms of their level of satisfaction with the specialized nursing services (p value = 0.53). Conclusion- Specialized nursing services for heart failure patients were able to make patients as well as family caregivers satised. Participants felt encouraged to follow the advice of healthcare professionals and to implement necessary changes in their daily life.

Keywords- Heart failure; Nursing services; Satisfaction

Corresponding author

Dr. Sukhpal Kaur, Lecturer,

National Institute of Nursing Education, PGIMER Chandigarh 160012, India

E mail id- drsukhpalkaur@gmail.com

Introduction

The burden of non-communicable diseases is alarming in low middle income countries including India.1 Heart failure is one of the chronic cardiovascular diseases with 20-30% mortality in admitted patients.2 The adherence to medications (guideline directed medical therapy) and their tolerance is quite low for Indian subset medication adherence and satisfaction with the care system among heart failure of heart failure patients.2 Hence, it is patients.10-12 recommended that patients should be taught about their illness, therapeutic regimen, dietary modications, exercise schedule and ways to identify the worsening symptoms. The role of healthcare providers especially nurses is to identify the abilities of patients and caregivers to understand and comply with the instructions necessary to improve their health.

Patients nd self-care of heart failure quite complex requiring strict adherence to medications, low sodium diet, symptoms monitoring and regular follow up. Not only the patients but caregivers who are actively involved in the care of heart failure patients feel enormous burden in their lives due to the disabling symptoms. 3-4 Specialized nursing services in the form of nurse led heart failure clinics have proven to reduce no. of deaths and hospitalizations in heart failure patients.5 As compared to the routine conventional care, the evidence based care rendered by specially trained nurses to manage heart failure has benetted the patients in a signicant manner.6 It has been seen that heart failure patients get more satisfaction with nursing services when their problems are addressed in `group.7-8 In a group  clinic  trial  (SMAC-HF)9,  heart  f a i l u r e p a t i e n t s h a v i n g c o m m o n complaints, found more satised as compared to individual appointment with heart failure nurses. The group clinics were able to improve quality of life, pattern of Considering the burden of caregiving in heart failure patients, it is equally important for the caregivers to be satised with heart failure management program. However, the satisfaction of caregivers and patients regarding specialized heart failure nursing services was less studied individually. We have found that the heart failure patients and their caregivers were asked about their satisfaction with nursing services either when they are still admitted or at the time of discharge from the hospital. Studies related to satisfaction of patients and their family members who visit ambulatory care settings like OPD or heart failure clinic are lacking. The difference in the satisfaction level of patients and caregivers and how it impacts the management of heart failure is still under evaluation. Thus, the current study was aimed to evaluate the satisfaction of heart failure patients and caregivers with specialized heart failure nursing services.

Objective:

To assess the level of satisfaction of patients and caregivers with the specialized heart failure nursing services for management of heart failure

Material and methods :

A prospective cohort study was conducted amongst patients suffering from heart failure. These patients were already enrolled in a pre-experimental study (CTRI/2018/05/014047). The protocol to provide the specialized heart failure nursing services for management of heart failure at home was developed and its effectiveness was evaluated. Specialized heart failure nursing services protocol on self-management of heart failure at home included functional capacity, activities of daily living and medication adherence in a tertiary care center of Northern India from December 2018-February 2019. Seventy participants were pre-assessed for above mentioned parameters and then enrolled in the study. They were taught about heart failure and ways to tackle it at home as per protocol. Patients along with caregivers were demonstrated individualized exercises and dietary modications based on their functional capacity. They were also instructed to evaluate themselves for few vital parameters like pulse rate, blood pressure, weight per week etc. Patients were followed up after three months of enrolment in the study for the same parameters and effectiveness of nursing interventions was established.

Instrument development :

A questionnaire was prepared with three sections: section A, section B and section C. Section A comprised of items to collect socio demographic details of both, the patients and caregivers and clinical status of  patients  only;  section  B  &  C  i ncorporated questions t o assess satisfaction level of heart failure patients and caregivers with specialized nursing services respectively. Questionnaire to assess the satisfaction of participants was prepared through literature review and consultation with the experts from the department of  Cardiology  and  nursing e d u c a t i o n . F a c e v a l i d i t y o f t h e questionnaire was assessed by a panel of ve experts. The questionnaire was pretested on ve patients from the cohort. Equivocal items were rephrased again as suggested by the panel of experts and result of pretest. The questionnaire to evaluate satisfaction of the participants contained closed ended questions to be rated on ve point Likert scale ranging from strongly disagree to strongly agree.

Patient satisfaction and caregivers’ satisfaction was assessed regarding various domains of nursing services like set up; knowledge of staff; adequate attention by the nursing staff; clear instructions about lifestyle modications and decision making etc. Both the questionnaires contained fteen items each. The content of all the items in two questionnaires was similar except for the reference of the subjects i.e. patients and caregivers.

Ethical considerations :

Written informed consent was obtained from all the participants or their legal representatives before enrolment into the study. The study was approved by Institute Ethics Committee,  PGIMER C h a n d i g a r h v i d e r e f e r e n c e n o . INT/IEC/2018/000542. Condentiality of the information obtained and identity of participants was ensured.

Twenty patients and twenty family caregivers were chosen purposively from the above mentioned cohort once they have completed their predetermined no. of follow ups. Participants were given a self- administered questionnaire to rate their satisfaction regarding nursing services being provided during their enrolment in the main study and scheduled follow ups. Questionnaires were provided in two languages i.e. English and Hindi based on p a r t i c i p a n t s ‘ p r e f e r e n c e s . E a c h questionnaire consisted of fteen questions regarding the set up of the clinic, knowledge of specialized heart failure nurse regarding heart failure, ability to tackle queries and making positive contribution to well-being of patients etc. The items in both the questionnaires were similar. The items were rated on ve point Likert scale where 1 stood for strongly disagree, 2- disagree, 3- neutral response, 4- agree and 5- strongly agree. None of the item was negatively coded. Sum of the scores for individual items were calculated. Total score ranged from 15-75. On the basis of it, level of satisfaction of participants was categorized into four categories i.e. highly satised (>70), moderately satised  (58-69), fairly satised (46-57), not satised (<45).

Statistical analysis :

Data were entered in Excel sheet and later imported to Statistical Package for Social Sciences (IBM SPSS statistics version 22, IBM, Armonk, New York, Westchester) for analysis. The data was described as mean standard deviation for continuous variables and frequency (percentages) for categorical variables. Normal distribution of the continuous data was tested using Kolmogorov Smironov. Independent t test was used for the comparison of continuous data with normal distribution. For the comparison of categorical data, chi square was used with or without simulation. The level of statistical signicance was kept at p= <0.05.

Results :

Total 40 participants i.e. 20 heart failure patients and 20 caregivers were included in this study. Among the heart failure patients, 15 (75%) were males and 5 (25%) were females. The mean age of patients was 54.15 ± 13.06 years. 12 (60%) were residing in rural areas while 8 (40%) were living in urban communities. Majority were married. Among the family caregivers, 13 (65%) were males. The mean age of the caregivers was 51.6 ± 13.67 years. Other characteristics of the participants are mentioned in table 1. 13 (65%) of the patients belonged to New York Heart Association functional class II which means they had slight limitation while carrying out ordinary activities. The average left ventricular ejection fraction of the patients suffering from heart failure was 30.25 ± 6.78%.

Both the groups were similar in age, gender, habitat, marital status, educational status, socio economic status and dietary habits as shown in table 1. A signicant difference was noticed in the lifestyle pattern of patients and caregivers (Chi square with Monte Carlo Simulation p value- 0.013).

Table 1- Characteristics of patients and family caregivers who rated their satisfaction regarding specialized heart failure nursing services

 

Characteristics	Patients n=20	Family Caregivers n=20	P value
Age (in years) 20-40 40-60 60-80	04 (20) 09 (45) 07 (35)	05 (25) 10 (50) 05 (25)	0.55#
Gender Male Female	15 (75) 05 (25)	13 (65) 07 (35)	0.496#
Habitat Urban Rural	08 (40) 12 (60)	08 (40) 12 (60)	1.00#
Marital status Single Married	02 (10) 18 (85)	0 20 (100)	0.147#
Educational status Primary school High school Graduate Post graduate and above	04 (20) 06 (30) 06 (30) 04 (20)	06 (30) 07 (35) 04 (20) 03 (15)	0.877†
Occupation Skilled Professional Agriculture Not working	02 (10) 07 (35) 02 (10) 09 (45)	04 (20) 03 (15) 07 (35) 06 (30)	0.483†
Socio-economic status Upper class Upper middle class Middle  class Lower middle class	09 (45) 03 (15) 05 (25) 03 (15)	05 (25) 05 (25) 06 (30) 04 (20)	0.516†
Lifestyle pattern Sedentary Mild worker Moderate worker	12 (60) 07 (35) 01 (05)	11 (55) 07 (35) 02 (10)	0.013†
Dietary habits Vegetarian Non vegetarian	11 (55) 09 (45)	12 (60) 08 (40)	0.102#
New York Heart Association class II III IV ambulatory	13 (65) 04 (20) 03 (15)	–

# Pearson Chi Square, † Chi Square with Monte Carlo Simulation

Mean age of patients- 54.15 ± 13.06, Mean age of caregivers- 51.6 ± 13.67, Left ventricular ejection fraction- 30.25 ± 6.78

Rating of satisfaction of participants with specialized nursing services for individual item of the scale is depicted in table 2 and table 3 for patients and family caregivers, respectively. Majority of the patients (90%) showed their strong agreement to the knowledge and skill of heart failure nurse, spending enough time during follow up (90%), making contribution towards their well-being (95%), easily understandable language (100%), carefully listening to their queries (100%). All of the patients suggested that the nurse led clinic should be a part of future health care facilities.

Table 2-Satisfaction of caregivers with specialized heart failure nursing services

N=20

Question	Strongly Agree f(%)	Agree f(%)	Uncertain f(%)	Disagree f(%)	Strongly disagree f(%)
The setup of the clinic was good.	02 (10)	08 (40)	09 (45)	01 (05)	0
The clinic staff had adequate knowledge & skills for the management of my condition.	18 (90)	02 (10)	0	0	0
The clinic staff attended me on time.	15 (75)	04 (20)	01 (05)	0	0
The trained heart failure Nurse spent enough time with me during my follow up visit.	18 (90)	02 (10)	0	0	0
Satised with my discussion with trained heart failure nurse.	17 (85)	03 (15)	0	0	0
The trained heart failure nurse made positive contribution to my well-being.	19 (95)	01 (05)	0	0	0
The     trained     heart     failure     Nurse explained the things to me in a way which was easy for me to understand.	20 (100)	0	0	0	0
The     Trained     heart    failure     Nurse carefully listened to me.	20 (100)	0	0	0	0
The clinic was easily approachable.	15 (75)	02 (10)	02 (10)	01 (05)	0
Trained heart failure Nurse gave clear instructions to me about my health.	13 (65)	07 (35)	0	0	0
The Trained heart  failure  Nurse provided me the help I needed to make changes in my lifestyle or habits that  may improve my health or prevent illness.	17 (85)	03 (15)	0	0	0
Trained heart failure Nurse motivated and encouraged me enough in decision making about my health.	17 (85)	03 (15)	0	0	0
The Nursing services for heart failure were helpful for me.	15 (75)	05 (25)	0	0	0
Doing exercises and maintenance of diary were helpful for me.	12 (60)	07 (35)	01 (05)	0	0
The Nurse Led clinic should be a part of future health care facilities.	20 (100)	0	0	0	0

 

Table 3- Satisfaction of patients with specialized heart failure nursing services

N=20

Question	Strongly Agree f(%)	Agree f(%)	Uncertain f(%)	Disagree f(%)	Strongly disagree f(%)
The setup of the clinic was good.	09 (45)	07 (35)	03 (15)	01 (05)	0
The clinic staff had adequate knowledge & skills for the management of my condition.	17 (85)	03 (15)	0	0	0
Clinic staff attended my patient on time.	10 (50)	09 (45)	01 (05)	0	0
The trained heart failure Nurse spent enough time with my patient during follow up visit.	20 (100)	0	0	0	0
Satised with my discussion with trained heart failure nurse.	19 (95)	01 (05)	0	0	0
The trained heart failure nurse made positive contribution to the well-being of my patient	17 (85)	03 (15)	0	0	0
The trained heart failure nurse explained the things to me in a way which was easy for me to understand.	19 (95)	01 (05)	0	0	0
The Trained heart failure nurse carefully listened to me.	19 (95)	01 (05)	0	0	0
The clinic was easily approachable.	16 (80)	03 (15)	01 (05)	0	0
Trained heart failure nurse gave clear instructions about my patient’s health.	15 (75)	05 (25)	0	0	0
The Trained heart failure nurse provided me the help I needed to make changes in my lifestyle or habits that may improve my health or prevent illness.	14 (70)	06 (30)	0	0	0
Trained heart failure Nurse motivated and encouraged me enough in decision making about my patient’s health.	13 (65)	07 (35)	0	0	0
The Nursing services for heart failure were helpful for me and my patient.	16 (80)	04 (20)	0	0	0
Doing exercises and maintenance of diary were helpful for my patient.	05 (25)	11 (55)	04 (20)	0	0
The Nurse Led clinic should be a part of future health care facilities.	19 (95)	05 (25)	0	0	0

All of the family caregivers strongly agreed that the heart failure nurse spent adequate time during their follow up. Majority of them showed their strong agreement towards their discussion with heart failure nurse (90%), careful listening to their queries ( 95 %), teaching in easily understandable language (n=95%), nurse led heart failure clinic as a part of health care facilities (n=95%).

Figure 1 depicts the satisfaction level of patients and caregivers with nursing services. Majority of the patients 15 (75%) as well as caregivers 18 (90%) were highly satised with the nursing services. Only few patients 5 (25%) and caregivers 2 (10%) were moderately satised. None of the patients and caregivers was found fairly or not satised. So the level of satisfaction among patients and caregivers was compared using Fisher Exact test. Both the groups were similar in terms of their level of satisfaction (p value = 0.53).

Table 4- Comparison of level of satisfaction regarding specialized heart failure nursing services among patients and caregivers

 

Level of satisfaction	Sum of scores	Patients	Caregivers	P value
Highly satised	>70	15(75)	18(90)	0.53*
Moderately satised	58-69	5(25)	2(10)
Fairly satised	46-57	0	0
Not satised	<45	0	0

*Fisher exact test

Discussion

Satisfaction of patients and their family members is a signicant contributor towards the adequate self-management practices of heart failure patients. The to a study by Aggarwal B et al. in which 73% of the caregivers were employed.16 Disparities were seen between lifestyle pattern of heart failure patients and their caregivers (0.013) as seen similarly in a extent to which the patients and their study by Seid et al.17 The reason behind families feel satisfy with the nursing services is directly proportional to their self-efcacy, empowerment and health literacy. Hence, this reduces their morbidity, no. of hospitalizations and overall healthcare burden.

Current s tudy highlighted the satisfaction of participants i.e. heart failure patients and their family caregivers regarding specialized heart failure nursing services . The mean age of patients was 54.15 years which was similar to AFAR study13 where the average age of participants was 53.5 years and majority of them (63%) were male patients. In the current study, the proportion of males is also high i.e. 75%. The mean age of family caregivers (51.6 years) was also consistent with a review by J. Nicholas Dionne-Odom patients being less active is that they have disabling symptoms of heart failure like easy fatigability, dyspnea and exercise intolerance. Another important nding by Seid et al. showed the difference in functional capacity of heart failure patients i.e. NYHA 65% vs 21.6%, NYHA III 20% vs 36.5%, NYHA IV 15% vs 28.4%. This reasonable difference is contributed by the improvement in functional capacity of patients after implementing nursing protocol as we chose the patients from a cohort at the end of experimental study.

The satisfaction of patients and their family caregivers at the time of discharge from hospital is important. National health service (NHS) Operating Framework requires opinion of patients regarding the care they received. The opinions of patients et al. 14 (55.9 years). The proportion of matter to Care Quality Commission as a patients and caregivers who were graduate and above was 50% and 35% respectively which was consistent with the ndings of Bidwell JT et al. who reported similar educational level in 47% of heart failure patients and 48% of family caregivers.15

The average left ventricular ejection fraction (30.25 ± 6.78) of heart failure patients in current study was also comparable with the participants of Bidwell JT et al. study (27.0 ± 13.7)15. 70% of the family caregivers of current study were earning their livelihood which was similar performance indictor. Moreover it can help health care workers to consider and act according to the responses of participants. Satisfaction of patients and their family members at the time of discharge should be measured so that home care planning can be optimally individualized.18 The current study was done in out- patient department of cardiology department which reported that the majority of the patients 15 (75%) as well as caregivers 18 (90%) were highly satised with the nursing services. All of the patients narrated that they were satised by specialized heart failure nursing services as they spent adequate time with them, and carefully l istened to them ( 95 %). Caregivers opined that, the trained heart failure nurses had adequate knowledge and skills to manage the problems of their patient (90%), made positive contribution towards their well being (95%), explained the medical information in easily understandable way (100%), carefully listened to their complaints (100%). All of them recommended nurse led heart failure clinic to be a part of routine care. Similar results were found in a study by Zrinyi and Horvath in 2003 who investigated “nurse patient interactions after cardiac event’.19 They stated that positive interaction of patients with the staff pose signicant effect on their healthy lifestyle pattern. Negative remark about set up of the clinic was made by one patient and one caregiver. However, due to lack of space in cardiology OPD, we couldn’t alleviate this issue. Another study by Oterhals et al. in 2006 revealed that satisfaction of patients with their hospital stay is directly proportional to the quantity of information they receive.20 Still there is a lack of studies revealing satisfaction of patients along with their caregivers regarding specialized heart failure nursing services . Strong agreement of patients and family members related to nearly all components of nursing services for heart failure patients was made but it requires further research to predict the relationship between satisfaction and self- efcacy.

Conclusion:

Specialized heat failure nursing services for heart failure patients were able to make patients as well as family caregivers satised. Participants felt encouraged to follow the advice of healthcare professionals and to implement necessary changes in their daily life.

Limitations:

The current study was limited to twenty patients and twenty caregivers from one hospital only. So selection bias could not be completely omitted.

Conflict of interest:

Authors declare no conict of interest in the present study.

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