W5- Foundations Of Nursing Research
Instructions
Using theWeek 5 research templateidentify the research components, listed on the template. Select a nursing research article from the list below and address each of the following criteria:
If a component is not present in the article, its absence should be discussed.
Identify the research problem.
Identify the research purpose.
Summarize the review of literature.
Identify the nursing framework or theoretical perspective.
Identify the research questions and hypotheses.
Identify the variables.
Identify and discuss the appropriateness of the design.
Describe the procedures for data collection
Discusses the validity and reliability of the instruments, tools, or surveys.
Describe the final sample.
Summarize the results including statistical analysis used or other method of analysis.
Discuss the significance of the study. Did it resolve the question?
Discuss the legal and ethical issues of the study. Include the use of human subjects and their protection.
Describe any cultural aspects of the study.
Describe how the results of the research may affect future nursing practice.
Apply the research to your nursing practice.
NOTE: If a component is not addressed, the student receives a zero for that component.
Sousa, J.P., & Santos, M. (2019).Symptom management and hospital readmission in heart failure patients. A qualitative study from Portugal. Critical Care Nurse Quarterly42(1), 81-88.
Nurses’ Preparedness and Perceived Competence in Managing Disasters
The Lived Experiences of People with Chronic Obstructive Pulmonary Disease: A Phenomenological Study
Zaken, Z.B, Maoz, E., Raizman, E. (2018).Needs of relatives of surgical patients: Perceptions of relatives and medical staff.MEDSURG Nursing27(2), 110-116.
Cite all sources in APA format.
NSG3029 W5 Project
Research Template Name
Cite the article reviewed in APA style:
***In the template, any direct quotes from the articles needs to only include the page number.
Week 5 Template
Check the correct method used in your article
Quantitative Qualitative
Identify the research problem.
Identify the research purpose.
Summarize the literature review.
Identify the nursing framework or theoretical perspective.
Identify the research questions or hypotheses.
Identify the variables.
Identify and discuss the appropriateness of the design.
Describe the procedures for data collection.
Discusses the validity and reliability of the instruments, tools, or surveys.
Describe the final sample.
Summarize the results including statistical analysis used or other method of analysis.
Discuss the significance of the study. Did it resolve the question?
Discuss the legal and ethical issues of the study. Include the use of human subjects and their protection.
Describe any cultural aspects of the study.
Describe how the results of the research may affect future nursing practice.
Apply the research to your nursing practice. Crit Care Nurs Q
Vol. 42, No. 1, pp. 8188
Copyright c 2019 Wolters Kluwer Health, Inc. All rights reserved.
Symptom Management and
Hospital Readmission in Heart
Failure Patients
A Qualitative Study From Portugal
Joana Pereira Sousa, MNSc, RN; Miguel Santos, PhD
This article reports a study aimed at identifying the factors that result in hospital readmissions for
patients with heart failure. The high rates of readmission are often due to a lack of knowledge
about symptoms and signs of disease progression, and these Portuguese nurses believed that read-
missions could be decreased through disease management programs in which patients assumed
a more active role in self-care. A study was designed to identify broad categories of problems
that lead Portuguese patients with heart failure to be readmitted to hospital. Semistructured inter-
views were conducted, recorded, and submitted for content analysis, revealing 3 main categories
for targeting: health management, behavioral management, and psychological support. This study
revealed that patients with heart failure seem to struggle with management of multiple treatment
regimens during the long course of their chronic illness. Based on these interviews, authors con-
clude that a disease management program be tailored expressly for the Portuguese culture and
their lifestyle. Key words: disease management, heart failure, hospital readmission, self-care
behavior
H EART FAILURE (HF) is considered amajor public health problem world-
wide1,2 and is expected to continue to
increase in coming years.1,3 HF is a life-
threatening event with fast onset,3 charac-
terized by fatigue, breathlessness at rest or
Author Affiliations: Instituto de Ciencias da Saude,
Universidade Catolica Portuguesa, Porto, Portugal
and Cardiology Unit/Heart Failure Intensive Care
Unit, Centro Hospitalar e Universitario de Coimbra,
Portugal (Ms Sousa); and Centro de Investigacao
Interdisciplinar em Saude – Instituto Ciencias da
Saude, Universidade Catolica Portuguesa, Porto,
Portugal (Dr Santos).
The authors thank Editage (www.editage.com) for
English language editing.
The authors have disclosed that they have no signif-
icant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Joana Pereira Sousa, MNSc, RN, Car-
diology Unit/Heart Failure Intensive Care Unit, Floor 3,
Centro Hospitalar e Universitario de Coimbra, Prac-
eta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
([emailprotected]).
DOI: 10.1097/CNQ.0000000000000241
on exertion, and fluid retention occurring
mostly in the legs, ankles, and lungs.3,4
Furthermore, it is associated with frequent
hospital readmission, poor quality of life,
high mortality, and financial problems.5-8
It has been previously reported that about
50% of the population in industrialized coun-
tries is at risk of being hospitalized with HF.9
In addition, these same patients are likely to
be readmitted to the health system within
6 months after discharge,9 leading to a health
system burden.10 Some of the main causes
for readmission include premature discharge
and educational and follow-up inefficacy, sug-
gesting that about half of these readmissions
could potentially be prevented.6,9,11 How-
ever, it is also possible that because of the
overwhelming level of responsibility regard-
ing disease management (eg, medication man-
agement, exercise, resting of the legs, and eat-
ing habits) and difficulty in coping with the
multiple lifestyle changes required by HF, it is
difficult for them to engage in recommended
self-care behaviors.11
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81
www.editage.com
mailto:[emailprotected]
82 CRITICAL CARE NURSING QUARTERLY/JANUARYMARCH 2019
Self-care can have different meanings,
depending on the underlying theory.4,12
According to Riegel et al,4 self-care is the
decision-making process through which pa-
tients adopt specific behaviors to main-
tain physical stability (eg, monitoring HF
symptoms and therapeutic adherence) and
promptly react when symptoms are first de-
tected. In the context of HF, these self-care
behaviors include adherence to the treatment
regimen, symptom monitoring, and preven-
tion of heart deterioration.6,9,11,13,14 In pa-
tients with HF, self-care behaviors include de-
tection of initial symptoms of the disease,
which allows them to make appropriate de-
cisions about the best course of action re-
garding the implementation of proper treat-
ment strategies.4,11 Riegel and colleagues11
further subdivided self-care into 2 additional
subtypes relevant to HF: self-care mainte-
nance (which involves the choice of behav-
iors that tend to maintain physiologic sta-
bility) and self-care management (which in-
cludes a response to symptoms when they
first occur). Based on these 2 types of self-
care for HF management, patients may ben-
efit from a 2-stage disease management pro-
gram (DMP). In this DMP, patients (1) would
be able to start a decision-making process and
(2) would learn about the disease to identify
health problems and implement strategies to
solve them.15 According to the European So-
ciety of Cardiology guidelines for HF, such a
program should be provided in specialized HF
clinics with health professionals (eg, nurses,
physicians, pharmacists, and physical thera-
pists) who are experts in this disease, with
the goal of developing specific HF care and
better outcomes.16,17
Although a previous study described the
main categories of problems for a sample of
patients from the United States,18 it is not
clear whether the same categories are present
in patients with HF from a southern European
country. In this study, the aim was to iden-
tify broad categories of problems that lead
Portuguese patients with HF to be readmit-
ted to hospital, through analyses of semistruc-
tured interviews with patients with HF, car-
diologists, and expert nurses in a cardiology
ward. Based on these interviews, the first in-
tent was to determine why patients with HF
do not contact their doctors or nurses when
symptoms first start (eg, weight gain, body
edema, or tiredness) and second, what health
care providers can do to meet patients needs
to engage them and change their behaviors.
METHODS
Design
This study was based on the frame-
work of complex interventions pro-
posed by the Medical Research Council
(MRC),19 which involves 4 phases: devel-
opment, feasibility/piloting, evaluation, and
implementation.19,20 This study represents
primary research, which is part of phase
I (development) of the MRC framework,
using qualitative methodology. According
to the MRC.19 complex interventions allow
a clear and detailed description of all the
components of the experimental and control
interventions, providing a better understand-
ing of the feasibility and effectiveness, as well
as optimizing dissemination and implemen-
tation of the experimental intervention. This
initial qualitative study allowed identification
of themes to be developed based on inter-
views with participants. In combination with
a systematic literature review, these themes
form the basis of a complex intervention to
be later implemented in a DMP. Therefore,
this study was designed to ensure that the
future choice of intervention would be based
on participants needs, rather than on the
researchers opinion or preference. In short,
the present study constitutes phase I of a
larger study that will be later evaluated in a
DMP for patients with HF.19,20
Sample
For this study, a convenience sample was
composed of 5 patients (Pt) hospitalized for
primary HF, 2 cardiologist physicians (C), and
3 nurses (N) who were experts in HF, from
a cardiology ward in Centro Hospitalar e
Copyright 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Hospital Readmission in Heart Failure 83
Universitario de Coimbra, Portugal. Inclusion
criteria for patients were being older than
18 years, admitted into an HF cardiac ward,
and consented to be interviewed for this
study. Patients were not currently involved in
a structured DMP; thus, they were receiving
little information about what to do if an esca-
lation of symptoms was detected.
Procedure
All participants were interviewed and ap-
proached face-to-face by the primary re-
searcher (J.P.S.), a registered nurse in this
setting, in a separate room of the cardiol-
ogy ward of Centro Universitario e Hospita-
lar de Coimbra. The cardiologist physicians
and nurses who participated were coworkers
of the primary researcher. The patients inter-
viewed had been admitted with chronic HF,
had an acute escalation in their symptoms,
were available at the time of the interview,
and consented to be interviewed for this
study. At the time of the interview, the pri-
mary researcher and the patients did not have
an existing relationship. The interviews took
place during a 2-month period and lasted ap-
proximately 30 minutes each. The semistruc-
tured interviews were recorded and followed
by verbatim transcription.
Analysis
Content analysis was conducted using the
NVivo 10 program for qualitative data, by the
primary researcher. After transcription, key
terms were identified, and themes emerged.
The coding process was reanalyzed 3 times,
wherein the main categories were narrowed
down from 4 to 3. Key terms were then reana-
lyzed to track variability of themes. Lastly, key
terms were grouped into main categories.
Ethical considerations
All participants provided written informed
consent for the interviews. The Committee
for Ethics of Centro Hospitalar e Universitario
de Coimbra approved this study. This investi-
gation also followed the principles defined in
the Declaration of Helsinki.21
RESULTS
Analysis of the semistructured interviews
revealed 3 main categories: health manage-
ment, behavior management, and support
received, which can be seen in the Table.
Health management
The category health management was re-
lated to patients knowledge about HF signs
and symptoms. It also included the ability to
follow the therapeutic regimen as specified
by health care providers (eg, prescriptions),
the ability to adopt a specific lifestyle, and
knowledge about when to contact the physi-
cian. Examples of this include the following:
I know I must walk a little bit every day.
Table. Emergent Themes From Semistructured Interviews
Emergent Themes Subthemes Participants
Health management Contact doctor when feeling worse
Follow providers prescriptions (eg,
exercise and diet)
Knowledge about heart failure signs
and symptoms
Patients (Pt1, Pt2, Pt3, and Pt4)
Cardiologist physician (C1)
Behavior management Lack of knowledge
Consciousness of lifestyle errors
Therapeutic noncompliance
Patients (Pt1, Pt2, Pt3, Pt4, and Pt5)
Cardiologist physician (C1 and C2)
Nurses (N1, N2, and N3)
Support received Longer and regular clinic visits
Home visits
Family and patient education
Telephone follow-up
Patients (Pt3, Pt4, and Pt5)
Cardiologist physician (C1 and C2)
Nurses (N1, N2, and N3)
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84 CRITICAL CARE NURSING QUARTERLY/JANUARYMARCH 2019
I should drink about a liter of water ( . . . ) and
not eat salty food and avoid sugars (Pt1), and
Yes, I am careful at home, with the amount
of water and food (Pt2). During interviews,
it was found that, of 5 patients, 4 mentioned
information related to symptom identification
(such as symptoms indicative of a worsening
health condition). For example, I am here
because of shortness of breath and swollen
legs (Pt4) or I walked two or three steps
and became distressed (Pt1). Most impor-
tantly, these patients were not only able to
identify these signs and symptoms but also
able to decide when they should contact
their physician. For example, then, I tele-
phoned my cardiologist (Pt1). In contrast,
health professionals generally did not men-
tion these symptoms in their interviews. Only
one physicianan exception to this trend
mentioned the following: to seek medical
advice and contact the medical and nursing
teams when there is a worsening of symp-
toms, for example, daily weight (if there is
weight gain) or starting to become tired or
short of breath (C1). However, neither the
other physician nor the nurses mentioned
these symptoms in their interviews (see the
Table).
Behavior management
This theme showed a general lack of
knowledge of the signs and symptoms of the
disease. For example, patients mentioned
that at medical consultation, the physician
told me to stay and be admitted to hospital
because of my health complaints (tiredness
and fatigue) (Pt3) and that I came to
the hospital only when I couldnt sleep
anymore, I slept sitting with several pillows
under my back. My legs were swollen . . .
(Pt3). In addition, patients also mentioned
being self-aware of not complying with the
required lifestyle. For example, one patient
mentioned, In reality, I should fulfill the wa-
ter restriction, but I drink much more than is
recommended. I struggle meeting this kind of
guideline because I have had this problem for
so long (Pt3). Meanwhile, another patient
mentioned that despite having the intent to
follow the health workers suggestions, work-
ing far from home made it difficult to change
behaviors related to self-care: I have been
working abroad for 24 years and it is really
hard to follow any kind of guideline because
I have lunch in restaurants and at night I eat
whatever I have. I come home every two
weeks (Pt3). One patient also mentioned
not obeying health care instructions, despite
being aware that this would most likely lead
him to hospital readmission: sometimes I
drink wine that I should not drink. Also [I
drink] beer and should be more careful with
the food [I eat] (Pt5).
Analysis of physicians interviews sug-
gested that changing self-care behaviors
might be hard for patients. One physician
mentioned that there are people for which
the intervention is not effective, even with
regular information sessions. This is either
because they do not have any nearby fam-
ily, or they live alone, or they are alcoholics
(C1). This physician concluded that the
biggest cause of heart failure decompensa-
tion is non-compliance. The interviews with
these physicians also suggested that patients
do not comply with the pharmacological reg-
imen and fluid restriction (C2). These pa-
tients also were not following a proper diet,
not exercising, in other words, not living a
lifestyle adjusted to his chronic disease (C1).
Analysis of nurses interviews revealed that
behavior management also included thera-
peutic non-compliance (N2), and not being
careful with food regimen and fluid and al-
cohol intake (N3). For nurses, the main fac-
tor in getting worse is the failure in fluid in-
take (N1). They mention that, even though
patients received information about their ill-
ness and about decisions to make when first
signs of complications were detected, after a
week or two they start to forget the education
received, if not recalled (N1). Other nurses
mentioned that patients have the notion that
they should not drink large amounts of liq-
uids, should not drink alcohol, and should not
smoke. However, they are not yet motivated.
There is some reason why they keep engaging
in inappropriate behaviors (N1). In addition,
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Hospital Readmission in Heart Failure 85
these nurses also mentioned that some pa-
tients may think that because they are tak-
ing the medication, they are controlled and
make food mistakes, apparently, due to lack
of knowledge (N2).
Support received
In this category, both patients and health
care providers mentioned the importance
of having regular visits. For example, one of
the patients explicitly mentioned, Instead
of making one annual visit to the physician
(in the clinic), these should take place more
regularly. I am willing to come to the hospital
more often and be assessed by a nurse
(Pt5). In the interviews, both physicians and
nurses suggested that, if a regular visit to the
clinic was not feasible, a telephone follow-up
should take place. According to the physi-
cians and nurses, health professionals should
be able to periodically ( . . . ) telephone our
patients to determine if they are following
the therapeutic regimen or not, and how
their weight is evolving. This is a way to
detect heart failure decompensation (C2);
or as a nurse put it, if they do not remember
( . . . ) I think there should be an effort from
us (healthcare providers), with a telephone
call, because eventually all the information
taught will be forgotten. Then there will
be the temptation (of increasing fluid in-
take . . . ), they will start to decompensate,
(N3) and eventually end up being admitted
to emergency care or the intensive care
unit.
As a possible solution for health and be-
havior management, physicians and nurses
suggested implementing a structured edu-
cational program. According to one nurse,
patients should receive several educational
sessions, which are fundamental; we should
implement educational sessions in all clinic
visits, because they (patients) need this kind
of education (N2). These sessions should
include reminding the patient about illness
progression and necessary lifestyle changes.
As one physician put it, first of all, the
concept of heart failure as a disease must be
well clarified. This includes why a patient
has heart failure and what he/she can do to
adjust his/her daily life (C1). In addition,
knowing when to take specific actions was
also considered a key feature, as mentioned
by a nurse: If a patient starts to feel shortness
of breath or tiredness, this patient should not
stay at home, because staying at home will
probably worsen the health problem, and the
patient will eventually arrive (at hospital) in
a deteriorated condition (N3).
During these interviews, it was also no-
ticed that some patients knew they should ad-
here to health care providers prescriptions
to avoid hospital admissions: what counts is
to meet the most guidelines (Pt5); however,
unfortunately, patients tend to forget if not
reminded.
DISCUSSION
Self-care is a decision process through
which the patient has the ability to
choose between different health-influencing
behaviors.2,3 This process helps patients
maintain an adequate physical status (moni-
toring signs and symptoms and therapeutic
regimen adherence), and prompts an early
and adequate response when necessary.4,11
In HF, self-care is believed to be relevant
because previous studies have demonstrated
that DMPs run by a multidisciplinary team
can lead to improvements in self-care, which
are followed by improvements in overall dis-
ease management.22 Specifically, explaining
pathology in nontechnical terms and training
patients to identify early signs and symp-
toms of the disease have been associated
with fewer hospital readmissions or shorter
stays.23 Although education seems to play a
key role in disease management, a previous
systematic review on HF education and
self-management24 described a gap between
the information given to patients and actual
performance of self-care in patients with
HF. Thus, even if information is given to a
patient, this does not necessarily mean that
he/she will be able to use it appropriately
at a later time. During this study, interviews
seemed to support these previous findings,
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86 CRITICAL CARE NURSING QUARTERLY/JANUARYMARCH 2019
with health professionals indicating that, in
follow-up visits, patients did not know which
strategies they should adopt to improve their
health status or in which situations they
should contact health professionals. These
findings generally support the notion that
giving information to patients is no guar-
antee of future adequate self-care. Instead,
these results indicate that, in addition to the
information given, health care professionals
should ensure that patients with HF have
actually understood the message and are
able to identify early signs and symptoms
of the disease. Lack of knowledge has been
reported to be the cause of patients not
recognizing signs and symptoms, leading to
delays in searching for specialized help.25,26
In addition, as found in previous studies,5 all
of those interviewed in our study (patients,
nurses, and physicians) considered manage-
ment of signs and symptoms to be a major
problem that should be addressed in a DMP.
According to them, this could be achieved
if the education program was followed by
telephone reminder calls.
These findings indicate that educational
programs for patients with HF should fo-
cus on self-care behavior, mostly in terms
of self-care maintenance and self-care
management.27 Self-care maintenance re-
quires counseling (by health care providers)
on therapeutic adherence, low-sodium diet,
physical exercise, preventive behaviors, and
an active monitoring of signs and symptoms
by the patient.2,3 Self-care management
focuses on patient decision-making, response
to signs and symptoms of illness, recognition
and evaluation of body changes (eg, edema
of some body parts), implementing treatment
strategies (eg, taking an extra pill when nec-
essary), and evaluating the response to this
process.4,11 In HF, self-care is mostly related
to self-care maintenance, in which patients
try to maintain physiological stability for a
longer period.7 As HF is a chronic disease,
achieving self-care will most likely require
a change in a patients behaviors and habits
and patients will have to continuously decide
what is best for their health.28
Our interviews showed that some patients
contacted health care providers as soon as
the first symptoms and signs appeared, while
others went straight to the hospital emer-
gency department. These results suggest that
there may be 2 different types of patients
with HF: those who understand relevant in-
formation and contact health care providers,
and those who do not understand the neces-
sary information and may need additional re-
inforcement or further learning periods.29 As
mentioned earlier, self-care can be subdivided
into self-care maintenance (ie, behaviors that
maintain physiologic stability) and self-care
management (ie, response to symptoms).11
Previous results and this study suggest that,
although both types should be targeted in a
DMP for HF, self-care management seems to
be particularly relevant.6
The present study interviewed patients
who were in a cardiology ward and were
not yet stable (ie, acute HF condition). In a
previous study conducted with a larger num-
ber of stabilized patients with HF,18 similar in-
terviews revealed 4 components/categories:
symptom recognition, symptom evaluation,
treatment implementation, and treatment
evaluation. Several variables could account
for the differences in categories between the
previous study and this one. For example, it is
possible that cultural differences, the number
of interviews (higher in Dickson et al18), in-
terviewing patients in different disease stages
(stable in Dickson et al18 and acute in this
study), or a combination of factors may have
an influence. However, despite these differ-
ences, it is noteworthy that the sequence
of disease management/symptom identifi-
cation/taking immediate adequate action is
common to both studies. This means that de-
spite cultural and methodological differences
of these studies, in both cases, the prompt
identification of disease-worsening situations
and taking appropriate actions was consid-
ered to be a fundamental issue. Thus, the re-
sults from this and the previous study indicate
that an important effort should be made to
ensure that HF DMPs improve patients with
HF ability to detect symptoms and respond
Copyright 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Hospital Readmission in Heart Failure 87
appropriately. Further support for this comes
from Ahmad et al,30 who found that distress
symptoms and illness were patients main rea-
sons for hospitalization, while patients be-
haviors such as diet and medication adher-
ence were identified by physicians as the
main reason for hospital admission.30 Note
that, in the study reported here, these reasons
(ie, distress symptoms, illness, and patients
behaviors) were grouped in the common
theme behavior management. Thus, thera-
peutic noncompliance and lack of knowledge
(about symptom escalation and the disease it-
self) seem to be the main motive for hospital
admission in our study, in Dickson et al,18 and
in Ahmad et al.30
Study limitations
The major limitations of this study are the
small sample size and lack of generalizability.
Even though it took place in a university hos-
pital, the ward into which patients with HF
were admitted had only 5 intensive care unit
beds and 5 intermediate beds. In addition,
hospital stays were usually long, preventing
more participants to be included in this quali-
tative research. In future research, it is impor-
tant to increase the sample size and settings
to encompass more patients and health care
providers to support these findings.
Implications
HF is a chronic condition that requires
symptom recognition by patients.
It is important to teach/learn about HF
symptoms to manage early signs of de-
compensation and contact health care
providers as soon as possible to avoid hos-
pital admissions.
Focusing on a step-by-step intervention can
be a useful strategy to improve self-care
management in patients with HF.
CONCLUSION
Overall, the results of this study support
previous findings, and suggest the need to im-
plement an educational program for patients
with HF. This program should, according to
our results, focus on 3 main categories of self-
management: health management, behavior
management, and support received. In addi-
tion, this and other studies indicate that a
DMP for HF should ensure that patients can
identify and act accordingly when changes
first occur in their health status.
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