Helping Patients with Heart Disease

Introduction 
One of the goals of the Affordable Care Act (ACA) was to increase the practice of preventive medicine (Obama, 2016). As preventive care is less common in the health care industry in the U.S. than is the practice of treating patients after they have already become ill (McGlynn, Asch, Adams et al., 2003), this study aims to increase preventive care among nurses through the application of health literacy, which can raise patients’ awareness of potential health problems that may be associated with their lifestyles.
Problem Statement
The specific health problem that this report focuses on is heart disease and the need to reduce the risk of its development in patients. As Torpy, Burke and Glass (2009) report, heart disease is the biggest cause of mortality among people in the U.S. As a preventive measure, nurses can use health literacy to raise awareness among patients about the risk factors associated with heart disease and prevention plans that can be adopted in order to mitigate the risk of heart disease becoming a problem for them.
Theoretical Approach
The two nursing theories that will be used to develop this case report are the theory of transcultural nursing and the theory of personal system empathy. Obtaining and utilizing a cultural competency can help one better implement a health literacy initiative in preventive care, according to Lie, Carter-Pokras, Braun and Coleman (2012). Cultural awareness and personal empathy are tools that nurses can use to identify the best ways to approach patients about issues that might be sensitive to their feelings or that might involve long-held beliefs or ideas about health, personhood, and life orientation. A nurse who can identify a patient’s cultural background, proceed with the practice of using health literacy so as to raise awareness about taking preventive steps to reduce the risk of heart disease, and help the patient to obtain a greater quality of health is a nurse who will address the issue of heart disease by focusing on one of the critical goals of the ACA, as proposed by President Obama.
Literature Review
The Framingham Heart Study identified the main risk factors associated with heart disease to be (Torpy et al., 2009):
· Men over the age of 40; women over the age of 45
· Family history of heart disease
· Smoking
· High blood pressure
· Diabetes
· Obesity
· Lack of exercise
· High cholesterol
· Excessive fat in the abdominal area
Preventive care associated with reducing the risk of heart disease includes: cessation of smoking, 30 minutes of exercise per day, obtaining medical treatment for hypertension (high blood pressure), a healthier diet (high-fiber, low animal fat—lots of fruits, vegetables and whole grains), watching blood sugar levels, and lowering one’s intake of high-cholesterol foods.
As Hruby and Hu (2015) point out, however, preventing the onset of heart disease might be easier said than done for many patients, who may not even realize they are at risk for this problem. For instance, patients may present for an unrelated (or seemingly unrelated issue) and a nurse could see after assessing the patient that the individual is indeed at risk for developing heart disease. One of the reasons that so many patients are presenting with these signs is that “with few restrictions on access to or availability of food, the prevalence of overweight and obesity in the USA climbed virtually unmitigated over the last 50 years” (Hruby & Hu, 2015, p. 674). In other words, the environment and customary ways of eating that have been ingrained in people in the U.S. over the past few decades are perfect for elevating risks for heart disease.
Presenting this information to patients can be particularly difficult, especially if patients are unaware of their condition or take offense to the impression that they are not being healthy in their lifestyle. A nurse must be careful to approach the issue with empathy and with cultural sensitivity so that the patient does not feel like he or she is being attacked or treated unfairly. Empathy is described as the ability to put oneself in another person’s shoes (Wiseman, 1996) and can be a strategic tool that empowers a nurse to approach a patient with social and emotional intelligence so that the right kind of preventive care can be delivered to the patient to help the patient address risk factors that could later lead to major harm (Tshuldin, 1989).
Approaching the patient with cultural sensitivity via the transcultural nursing model can also be helpful in helping patients to understand the risks they face. The goal of the transcultural model is to give the patient quality care from within the patient’s own cultural framework (Maier-Lorentz, 2008). By showing knowledge of a patient’s cultural background and beliefs and approaching those beliefs empathetically, the nurse can help to establish a strong relationship with the patient, which will support the nurse’s efforts to practice preventive care (Che, Barret, Velez et al., 2014).
Nursing constitutes a succession of methodical steps aiming to offer excellent care. Its five stages are: assessment, diagnosis, planning, adoption and appraisal (Edwards, Staniszewska & Crichton, 2004). Using empathy and the transcultural model can help nurses to plan a preventive care approach, encourage the patient to adopt it, and assist in the appraisal of the intervention.
Health literacy can be used in preventive care as it works to raise the awareness of the patient about risks and to lean about procedures that can be implemented as a matter of daily habit in order to prevent disease from occurring (White, Chen & Atchison, 2008). Through the application of health literacy, using materials such as pamphlets and fliers that can be obtained from sources online as well as from organizations like the IOM or CDC, nurses can intervene with health literacy while adopting the empathetic and transcultural nursing approaches to ensure that respect for the patient is shown at the same time that important knowledge is conveyed and preventive care is delivered.
Case
The example case for this study would be an Indian patient who presents for a broken foot. The nurse notices that the patient is overweight, has excessive fat around the abdominal region, and upon further questioning the patient reveals that he does not exercise, smokes every day, and eats a high-cholesterol American diet of fast food with sugary drinks like soda and sweetened tea. The patient is a male of 45 years of age. The patient has not been checked for diabetes and it is not known whether there is a family history of heart disease. Upon checking the patient’s blood pressure, it is revealed to be high. Thus, 7 of 10 risk factors for heart disease are identified by the nurse. Though the patient has presented for a broken foot, the nurse immediately realizes that this would be a perfect opportunity to practice preventive care.
The preventive care that could be implemented here is first for the nurse to schedule a test for diabetes. The nurse should use the transcultural model and the empathetic approach to next discuss with the patient some of the patient’s lifestyle choices, such as smoking, diet and exercise habits. The transcultural model is applied by considering the following aspects (Giger & Davidhizar, 2002):
· Time
· Space
· Social organization
· Communication
· Environmental control
· Biological variation
Being aware of these indicators will provide the nurse with useful information about the best way to approach the patient. How the patient uses space to keep distance, how the patient displays a sense of time (have they been waiting long, not long at all, do they feel neglected—and so on), how the patient views his or her biology, how the patient communicates (openly or in a closed manner)—all of these variables will contribute to the cultural lens that the nurse uses to obtain information from the patient before engaging in preventive care through the application of health literacy.
Transcultural nursing can allow the nurse to apply cultural competency to the task of practicing preventive care by using practical steps to indicate respect for the patient. These steps can include being mindful about how the nurse stands, the proximity to the patient as treatment plans are discussed, the tone of voice that the nurse employs, how the nurse makes suggestions regarding care options (whether the nurse includes the patient in the process of making decisions vs. the nurse adopting an arbitrary tone and an isolating approach to the patient’s inputs). The point of this mindfulness is that how a nurse presents him or herself to the patient conveys meaning, depending on that patient’s cultural background. A nurse who is culturally aware, will understand the right signals to send through both verbal and non-verbal communication techniques so that the nurse demonstrates both empathy for the patient and support for the patient’s well-being. The patient should perceive that the nurse really has the patient’s best interests at heart and is approaching the patient’s health like a true friend.
Giger and Davidhizar (2002) make the important point of showing that patients from various cultural backgrounds will have varying points of view when it comes to what is appropriate for one’s lifestyle. With the case of the Indian patient, the nurse might find that the patient prefers to eat Western food because he feels that this is what one should do in America and that he is very conscious of fitting in. In this case, the nurse might explain to the patient that many Americans actually make conscious steps to avoid fast food in preference for organic meals that are nutritional and healthy. By helping the patient to identify the underlying motivations for poor health choices, the nurse is engaging in preventive care and can then supply the patient with health literature regarding heart disease that will be ready and waiting for distribution. As the nurse makes the patient feel more comfortable about this surprise (remember, the patient came for a broken foot and is now being given preventive care for heart disease) by including the patient in on the discussion of prevention, the nurse helps to focus on the patient’s experience in the facility and ensures that the patient remains the focus of the care. By engaging with the patient in a culturally-oriented way that is empathetic and geared towards preventive care, the nurse can identify along with the patient what is truly most important in the patient’s life and how a healthy approach to whatever is most important can be achieved so as to mitigate the risks associated with the patient’s present lifestyle situation.
The Institute for Health Care Improvement (2014) has shown that the transcultural assessment tool is helpful for nurses in establishing how to interact with persons of different cultures. The model developed by Leininger depicts the relationship between the factors associated with the transcultural model and how they inform the nurse’s empathetic approach to care. These factors include religion, family, life, political beliefs, cultural ideas, and educational background. Getting to know the patient, in other words, can help the nurse to identify the right way to bring up the topic of health. If the patient is educated, the nurse may find it more appropriate to take a scholarly approach to the subject. If the patient is uneducated, the nurse might find that a more practical or down to earth approach helps.
For nurses, Melo (2013) shows that the transcultural model is useful in developing “abilities and competencies to identify and understand the multiple factors that influence care, as well as comprehend it from a holistic-humanistic perspective” (p. 20). A nurse can thus best help a patient with treatment or with preventive care by understanding the relationship between culture and communication, which is what the model demonstrates.
The model shows how worldview connects with cultural and social structure dimensions. The nurse enters into these dimensions when engaging with the patient about health related issues. The nurse should be mindful of the patient’s worldview and engage in a plan to understand it by way of conversation, identifying clues about the patient’s cultural worldview through paying careful attention to what the patient says and how the patient says it.
The nurse may pay attention to the patient’s attitude towards technology, the patient’s attitude or thoughts on philosophical principles or on religion, the patient’s attitude towards friends and family, the patient’s attitude towards what is most important in life in terms of values and goals, the patient’s attitude towards politics, the patient’s attitude towards the economy, and the patient’s attitude towards education.
The information that the nurse obtains through conversation and the clues that are given regarding these areas will help the nurse to develop a socially and emotionally intelligent pathway to the patient that is both sensitive and respectful of the patient’s values and simultaneously informative regarding the patient’s need to begin implementing a preventive care process so that, in the case of the middle-aged, male Indian patient, a better lifestyle can be adopted. In the case of this patient, the nurse must develop a strategy that will raise the patient’s awareness of how smoking can be a risk factor for heart disease, how a poor diet and lack of exercise can all contribute to this risk, and what the patient can do to address these issues. Finding the right way to appeal to the patient is critical for success, but the empathetic approach allows the nurse to immediately be presented as an appealing person so that the patient will want to hear what the nurse has to say.
The transcultural approach helps the nurse to maintain this appeal by identifying that which is important to the patient. A nurse who cannot identify the important values of the patient is a nurse who is flying blindly in providing quality patient-centered care. The nurse will not be as completely aware of the patient’s sense of value as possible, and this will limit the flexibility with which the nurse can approach the situation. The more cognizant that the nurse is of the patient’s values, beliefs, and goals, the more room the nurse has to work in making a convincing case for the patient to begin to exercise preventive care.
Once the patient has confirmed that the he is in needed of mitigating the risk of heart disease, the nurse may begin to use health literacy to help the patient understand these risks more deeply and what procedures can be implemented to reduce them. The patient along with the nurse can collaborate on a plan that will help the patient to reduce body weight, change diet, give up smoking, and overall adopt a more healthy lifestyle. This is the true essence of holistic care and the success of the approach is likely to depend a great deal on how well the nurse is able to come to terms with the patient’s own cultural preferences and sense of value.
In order to measure that success, however, it is important for the nurse to survey the patient in a follow-up which may take place one month following the intervention. The nurse can then survey the patient to obtain data on the extent to which the intervention has made a difference in the patient’s life. The method and the evaluation process are described in the next section. Below can be seen a graphic image of the transcultural model.

Research Instrument and Evaluation Method
The appropriate research instrument for this case study would be the survey method with the Likert scale used to obtain a quantitative dataset to statements made in the survey. The patient would respond to the survey to indicate whether the approach used by the nurse was helpful or unhelpful in leading the patient to the optimal level of quality care. The survey would be given to the patient after a follow-up call one month after the patient’s discharge. This would allow the patient time to put the recommended practices into effect to see if there has been any change in health perception.
The survey would include statements such as:
1) The nurse’s discussion with you about risk factors associated with heart disease was satisfactory. Answer from 1 to 5, with 1 being “completely disagree” and 5 being “completely agree.”
2) You have implemented the nurse’s recommendations for preventive care in a meaningful way. Answer from 1 to 5, with 1 being “completely disagree” and 5 being “completely agree.”
3) The nurse was very respectful of your person and your beliefs when discussing with you health issues and potential preventive practices. Answer from 1 to 5, with 1 being “completely disagree” and 5 being “completely agree.”
The answers to these questions would then be measured using the Likert scale data and statistical analysis would be obtained using chi-square test method and Mann-Whitney test method after a significant sample of cases has been obtained.
This evaluation method would help to show whether the intervention of preventive care through the application of health literacy, using the empathetic and transcultural nursing model approach, is effective in helping patients to reevaluate their lifestyles and make corrections over a one-month period following the nurse’s intervention. The survey would be used to measure the variables described above and these measurements would be related to outcomes, which the chi-square and Mann-Whitney would show correlation of and goodness of fit for the statistics. The more patients that are included in the sample, the better the statistical evidence will show a meaningful evaluation.
Conclusion
In conclusion, the philosophical approach to nursing that a nurse possesses will impact the type of care that the nurse provides to the patient. The more empathetic and mindful of cultural beliefs and differences in terms of expectations and desires, the more likely the nurse is to have a positive impact on the patient’s health. In the case examined in this study, it has been shown how a patient with a particular cultural background can be approached with sensitivity and respect when the nurse uses the transcultural model. The model allows the nurse to identify various factors that will shape the patient’s perspective and once this perspective is understood, the nurse can integrate this knowledge into a respectful and empathetic approach to practicing preventive care. By then collaborating with the patient to identify goals that would be consistent with a healthy lifestyle, the nurse and the patient can together develop a plan to help mitigate the risks associated with the patient’s present health issue, applying health literacy to raise the patient’s awareness of risks and prevention methods. The survey method and statistical analysis, using chi-square and Mann-Whitney methods, can then be conducted in order to evaluate the extent to which this approach is successful one month later.
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