Discharge Education to Promote Self-Efficacy in Heart Failure

Introduction

Management of congestive heart failure (CHF) continues to be a financial burden on the economy of the United States. The disease is responsible for multiple hospital admissions and readmissions of patients within thirty days post-discharge, and has been associated with personal, physical, and economic challenges. As the population grows, the number of individuals affected by this condition is also increasing. According to the American Heart Association (2009), an estimated 400,000 to 500,000 new cases occur annually, with an additional annual cost of more than $33 billion added to the U.S. economy.

Discharge education, which attempts to reduce readmission rates, has become a valuable metric in the provision of health care. For effective management of heart failure symptoms, patient education is a necessity (Gruszczynski, 2010). Sara Paul (2008) discussed the importance of educating patients and their families in preventing re-hospitalization for heart failure. Evidence-based practice from the Heart Failure Society of America (HFSA), the European Society of Cardiology (ESC), the American College of Cardiology (ACC), and the American Heart Association (AHA) all recommend that heart failure patients receive individualized discharge education with emphasis placed on self-care. They also recommend that HF patients receive educational materials as part of their discharge instructions (Paul, 2008). Studies have shown that patients hospitalized with heart failure who received discharge education had an overall 20% improvement in compliance with their medication one year after discharge (Gwadry-Sridhar et al., 2008).

The purpose of this project is to evaluate the effectiveness of a discharge educational program for heart failure patients in order to increase their knowledge of self-care and improve self-efficacy.

Heart failure (HF) is a major and increasing health problem that affects patients, families, and communities. Approximately 5.7 million Americans have HF, with 10 per 1,000 new cases reported each year after age 65 (Roger et al., 2012). Heart failure ranked third among hospital discharge diagnoses — behind live births and pneumonia — in 2007 (Vreeland et al., 2011). The annual number of patients hospitalized with HF has increased from 800,000 to over 1 million for HF as a primary diagnosis, and from 2.4 to 3.6 million for HF as a primary or secondary diagnosis (Fang and Croft, 2008). In an effort to decrease the readmission rate of HF patients, institutions are seeking ways to improve patient care (Chen et al., 2010). Reducing readmissions has become a priority and a metric of quality of care among health care providers, health plans, government agencies, and other stakeholders.

Heart failure is a chronic cardiac condition particularly prevalent among the elderly population, characterized by high mortality and hospitalization rates (Dickstein et al., 2008). HF is described as the inability of the ventricles to fill or eject blood appropriately. The heart tends to weaken over time, allowing fluids to accumulate and producing symptoms of shortness of breath, bilateral peripheral edema, hepatic congestion, restlessness, and sometimes confusion (CDC, 2006). These symptoms occur due to the increased demand on the heart to work harder in order to ensure adequate oxygenation to the brain (Hallett, 2011). Patients may also experience an inability to perform their activities of daily living (ADL).

HF is commonly prevalent among individuals aged 65 years or older who present with co-morbidities such as atrial fibrillation (AF), hypertension (HTN), hypotension, hyperlipidemia (HLD), diabetes (DM), gout, coronary artery disease (CAD), and renal insufficiency (AHA, 2009). Heart failure patients commonly have multiple chronic diseases, which dramatically increases the rate of readmission (Manning, 2011). In a large retrospective controlled study, the risk of preventable hospitalization increased dramatically with the number of chronic diseases. Of the many identifiable simultaneous conditions, depression is also a major concern that is commonly overlooked. Depression affects nearly half of all heart failure patients and disturbs their ability to both learn and maintain their medical regimen. For these reasons, it is imperative that patients with high-risk comorbid conditions receive increased education and support (Manning, 2011).

The Centers for Medicare and Medicaid Services (CMS) announced in 2012 that it would become policy to decrease reimbursement and add penalties to institutions with high readmission rates for any cause of readmission within thirty days of the initial admission. Due to the proposed changes by Medicare and the Affordable Care Act, many institutions have focused on improving their performance and increasing emphasis on decreasing readmissions, especially in the heart failure population.

Theoretical Framework: Bandura's Self-Efficacy Theory

The methodological framework chosen to guide this project was developed by Albert Bandura. His social cognitive theory, published in 1997, focused primarily on the concept of self-efficacy. According to Bandura, self-efficacy refers to the personal belief that individuals have in their capability to learn and perform particular behaviors, and is domain-specific (Bandura, 1997).

The most influential source of self-efficacy information is the interpreted result of one's previous performance, or mastery experience. Individuals engage in tasks and activities, interpret the results of their actions, use those interpretations to develop beliefs about their capability to engage in subsequent tasks or activities, and act in accordance with the beliefs created (Resnick, 2009).

The concept of self-efficacy has been broadly used as a model for examining health-promoting education in areas such as cardiac rehabilitation, smoking cessation, dietary modification, and medication compliance (Kasikci et al., 2011). Bandura postulates that the outcomes an individual expects are the results of the judgment of what he or she can accomplish, and that outcome expectations are unlikely to contribute independently to predictions of behavior (Bandura, 1986). This theory focuses on the patient's belief in his or her ability to make changes, maintain those changes, and obtain positive outcomes in their lives. One key component in the heart failure population is monitoring daily weight. When weight gain occurs, the individual should initiate action by calling their physician or adjusting the dosage of their diuretic in order to reduce weight gain. The concept of self-efficacy is applied in this study to elicit behavioral changes in the heart failure patient.

Literature Review

Admission rates for HF patients are at an all-time high; data are reported at 2% within 2 days, 20% at 30 days, and 50% at 6 months after discharge (Mahramus et al., 2013). Currently, heart failure has become a global epidemic with no known cure. The American College of Cardiology Foundation/American Heart Association has found that preventable readmissions result from failure to consistently adhere to medical, dietary, and self-care principles. They strongly recommend instructions in areas such as weight monitoring, maintaining a treatment plan for worsening symptoms, and scheduling follow-up appointments. Studies have shown that effective discharge education is a vital component in improving outcomes in heart failure patients (Paul, 2008).

Kripalani et al. (2007) report that the period following hospital discharge is a vulnerable time for patients, because approximately half of these patients experience a medical error after leaving the hospital. Patients may experience an adverse drug event post-discharge, which represents one of several challenges in providing high-quality care as patients transition from the hospital. These challenges include discontinuity between hospitalists and primary care physicians, changes to the medication regimen, and the need for closer medical follow-up and adequate patient education about medication use. There is a vital need for effective transitions of care, improved communication between inpatient and outpatient physicians, and effective reconciliation of prescribed medication regimens (Kripalani et al., 2007). According to the Heart Failure Society of America (HFSA), heart failure patients and their families should receive individualized education that highlights the importance of self-care. Self-care is defined as the process by which individuals perform daily activities to maintain health. The HFSA further recommends that all patient education and counseling be provided by a qualified nurse with expertise in HF management, including dietician and pharmacist participation (Boyde et al., 2011).

Discharge counseling is a pivotal element and should concentrate on the key points of greatest importance to the patient, such as major diagnoses, medication changes, dates of follow-up appointments, and whom to contact if problems arise (Kripalani et al., 2007). Furthermore, the patient's understanding of these key concepts should be reinforced by hospital nurses prior to discharge.

Conclusion

Readmission rates in high-risk heart failure patients can be reduced if the proper evidence-based guidelines for discharge education are followed. If these guidelines are not followed, the likelihood that patients will adhere to their treatment regimens and attend follow-up appointments is reduced — and this non-adherence remains the most common reason for acute heart failure readmissions. In order to reduce these admissions, hospitals should implement models that deliver intensive education to high-risk heart failure patients. Hospitals should support, guide, and educate HF patients as they transition from the hospital to the home (Paul, 2008).

Effective discharge education is a multifaceted intervention that addresses not only knowledge deficits but also the patient's confidence and capacity for self-management. Grounded in Bandura's self-efficacy theory, such interventions empower patients to monitor their own symptoms, adhere to prescribed regimens, and seek timely medical attention when needed. The evidence consistently demonstrates that structured, nurse-led, individualized discharge education programs improve outcomes, reduce readmissions, and enhance quality of life for patients living with heart failure.

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