A quasi-experimental study examining a nurse-led educational program to improve disease knowledge and self-care for patients with acute decompensated heart failure with reduced ejection fraction

Materials and methods. An evidence-based, standardized educational program was implemented for HF patients in Poland. We compared the initial level of HF knowledge – as rated using a self-developed questionnaire and self-care behaviors, evaluated according to the 9-item European Heart Failure Self-care Behavior Scale (9-EHFScBS) – to the results obtained at the 3-month follow-up period with a sample of patients (n = 231) hospitalized with acute decompensated HF (ADHF).


Background
Heart failure (HF) is an important public health problem, with an estimated prevalence of 1-2% among adults and >10% among people aged >70 years in developing countries. 1 In Poland, over 700,000 patients suffer from HF, which can lead to premature death. 2,3 Heart failure requires multidisciplinary management programs, including self-care education. 1,4,5 Indeed, self-management interventions often led by nurses are effective at improving knowledge, self-care behaviors, quality of life, and reducing the number of hospitalizations and mortality among patients with HF. [6][7][8][9][10][11][12][13][14][15][16] Furthermore, the active post-discharge monitoring of patients with HF (e.g. via post-discharge phone calls) should translate into better adherence, a reduction in the number of decompensated HF cases and slower disease progression. 1,17 The European Society of Cardiology (ESC), American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) practice guidelines recommend a nurse-led HF education in HF patients. 1,4,5,18 The correlations between patients' knowledge of HF and self-care skills were found in studies conducted in the USA. 13,19 To meet this need, multidisciplinary HF programs, including various types of nurse-led interventions, should be implemented. 1,18,[20][21][22][23] Similarly, a disease management system for patients with HF named "KONS" (Comprehensive Care for Patients with Heart Failure) was proposed in Poland. 24

Objectives
The purpose of this study was to implement a standardized nurse-led HF education program focused on improving disease knowledge and self-care behaviors in patients hospitalized with acute decompensated heart failure with reduced ejection fraction (HFrEF) and evaluate its effectiveness.

Study population and design
"The Weak Heart" program was a nurse-led HF educational program conducted in 2019 in 14 cardiology centers in Poland and consisted of 2 hospital educational visits and 3 post-discharge phone calls. Prior to initiating patient education, nurse educators completed HF training and certification in accordance with the HF nurse curriculum developed by experts of Nurses and Medical Technicians and the Heart Failure Section of the Polish Cardiac Society. 25 Total number of 259 patients hospitalized due to acute decompensated heart failure (ADHF) were consecutively recruited based on the following inclusion criteria: diagnosed HF with reduced ejection fraction (ejection fraction (EF) < 40% as evaluated using echocardiography), cognitive function enabling the participation in the program and a declaration of the patient's involvement in the treatment; there were no exclusion criteria to enter the program. To assess the effectiveness of the program in a clinical setting, a prospective, quasi-experimental, pre-test and post-test method was applied.
"The Weak Heart" program was based on HF guidelines of European Society of Cardiology 1 and tailored to the needs of patients with HFrEF. The scope of education included the following topics: basic information about HF, etiology, symptoms, principles of self-care, basics of treatment, and the importance of lifestyle, diet and exercise, based on the content from patient portal (www.slabeserce. pl) displayed on tablet. After completing educational sessions, participants received a heart failure passport 26 with an individual treatment plan, a cover letter to primary care physician and a drug dispenser. A detailed description of "The Weak Heart" educational program has already been published. 27

Ethical aspects and recommendations
The Bioethical Commission at the University of Warsaw has approved the project (approval No. KB/3/A/2019). The study was performed in accordance with the ethical principles for clinical research based on the Declaration of Helsinki.

Data collection
Trained HF nurses interviewed participants using the questionnaires to assess the level of HF knowledge and self-care behaviors. Measurements were conducted before the implementation of any educational activities (visit 1), before discharge but after finishing all educational activities (visit 2 -only for the assessment of HF knowledge) and at the end of the 3-month follow-up period (visit 5).

Instruments
The research team has developed a 10-item HF knowledge questionnaire to assess the level of disease knowledge. Patient's responses were scored on a scale from 0 to 2 (0 -incorrect response, 1 -partially correct, 2 -correct), based on key words. The maximal score was 20 points -the higher the score, the better the level of HF knowledge. The calculated Cronbach's alpha for the knowledge test was 0.86. The value of the correlation coefficient of individual test items was not less than the minimum acceptable value of 0.20.
The 9-item European Heart Failure Self-care Behavior Scale (9-EHFScBS) contains 9 statements concerning self-care behaviors among HF patients. 28,29 The answers to the statements were given on the 5-point Likert scale, with the result being the aggregation of the points from all statements included in the 9-EHFScBS. The scores vary from 9 to 45 -the higher the score, the lower the selfcare capability. The questionnaire also enables the assessment of the level of self-care in terms of individual statements. 28,29 Additionally, a patient's self-care can also be measured by computing the scores for each subdimension of self-care: consulting behavior, autonomy-based adherence and provider-based adherence. 30 The calculated Cronbach's alpha for the behavior test was 0.89.

Statistical analysis
Statistical analysis was performed using SAS® software v. 9.4 (SAS Institute, Cary, USA). The Friedman's test was applied to verify the hypotheses of influence of the intervention program on scores of the knowledge test. Time of measurement was considered the within-group factor: before the commencement of the program (visit 1) compared to directly after finishing all educational activities (visit 2) compared to 3 months after its end (visit 5). The Bonferroni correction was used to adjust the significance value for multiple tests. The adjusted significance level was 0.017.
The Spearman's rank correlation coefficient was used to verify the correlation between scores on the 1 st knowledge test and duration of the disease. The Mann-Whitney U test was conducted to compare the scores of patients participating in any educational activities on HF with those who did not, as well as patients who required several hospitalizations and those hospitalized for the first time.
The verification of assumptions about the impact of the intervention program on self-care behaviors and subjective knowledge was carried out using the Wilcoxon test. Time of measurement was considered the within-group factor: before the commencement of the program (visit 1) compared to 3 months after its end (visit 5). A two-tailed value of p < 0.05 was considered significant for all tests.

Results
The final analysis consists of 231 patients who signed written consent and fulfilled all educational visits, while a sample size of 199 patients was required to achieve a statistical significance of p < 0.05. 27 Out of 259 patients included in the program, all visits were finished regarding 89% of patients (Fig. 1). The baseline characteristics of patients included in the study are presented in Table 1.
The results showed a significant difference in performance in the level-of-knowledge test depending on the time of measurement (χ 2 = 356.526, p < 0.001). The scores from the 1 st measurement were significantly lower than those from the 2 nd (Z = −1.227, p-value adjusted with Bonferroni correction (p adj ) <0.001) and 3 rd measurement (Z = −1.649, p adj < 0.001). The scores from the 2 nd measurement were significantly lower than those from the 3 rd measurement (Z = −0.422, p adj < 0.001). The results are presented in Table 2. Asignificant improvement in HF knowledge has been observed for all individual questions (Fig. 2).
The results demonstrated that patients educated on HF prior to the program, patients who underwent several • 231 (89%) paƟents finished visit 5 3 (1.2%) died, 2 (0.8%) refused to conƟnue, 2 (0.8%) did not pick up the phone • hospitalizations and with long-lasting HF scored better on the knowledge test compared to patients not educated previously, hospitalized for the first time and with HF de novo ( Table 3).
The results indicate that self-care behaviors improved after the intervention (Z = −7.317, p < 0.001 (higher score means lower self-care capability)). Enhanced autonomous-based adherence type of self-care behaviors (Z = −5.870, p < 0.001) was demonstrated. The level of consulting behavior also significantly increased after 3 months following the intervention (Z = −7.238, p < 0.001). Likewise, the level of provider-based adherence behaviors was more frequent after 3 months of follow-up than prior to the intervention (Z = −4.162; p < 0.001). The significant improvement in self-care was seen in all individual questions except statements 7 ("I eat a low salt  diet") and 9 ("I exercise regularly") of the 9-EHFScBS questionnaire (Fig. 2).
All patients were educated about the importance of posthospital ambulatory visits and treatment optimization. Most patients fulfilled their individualized post-discharge treatment plan (Fig. 3).

Discussion
Like previous studies, we found disease awareness and self-management skills initially poor among Polish patients with HF. [31][32][33][34][35] However, "The Weak Heart" model, prepared based on HF guidelines and practical recommendations, 1,4,7,36 was effective in enhancing HF patients' knowledge and developing self-management behaviors. In the study, the education program was delivered by a certified nurse educator working in a given cardiology ward. From a practical perspective, it is worth mentioning that 3.5 h in total were allocated to an individual patient's education. Based on nurses' feedback, in most cases, the time devoted to education was sufficient from the patient's point of view, but it caused a considerable burden on staff. Therefore, there is a need to introduce a qualified HF educator working in the cardiology wards responsible for patients' education, or to consider group education instead -to reduce the staff burden.
This observation is of significance since previous metaanalysis showed that self-management interventions in patients with HF improve the outcomes. 11,22,35 Therefore, evidence-based educational programs should be considered when designing multidisciplinary programs of coordinated care. 24 Unfortunately, any direct comparison of the effectiveness of our program with other educational interventions of this kind is difficult due to the heterogeneity of the design and methodology used in the research (Table 4).
Telephone support may reduce mortality and hospitalizations and improve quality of life among patients with HF. 20,21,35 Currently, it is the most commonly used monitoring strategy. 39,[41][42][43] We found post-discharge phone calls performed by nurses had an additional, positive effect on patients' HF knowledge and self-care behaviors. Yet another important strategy is to deliver educational programs during hospitalization, as patients after an acute episode are at a higher risk of recurrent hospitalizations. 43 Moreover, it helps in building a trusting relationship with patients and caregivers. 38,39 The time of hospitalization can also be used successfully to teach patients perform regular pulse, blood pressure and weight measurements, which was well received by participants of our program.
Early ambulatory visits within 7 days of discharge may lower the risk of hospital readmissions for patients with HF. 20,21,42,44 According to the study by Chuda et al., 45 over 90% of cardiac ward patients were referred to cardiac   9-EHFScBS -European Heart Failure Self-care Behavior Scale; DHFKS -Dutch Heart Failure Knowledge Scale; SCHFI -Self-Care of Heart Failure Index; ESC -European Society of Cardiology; N/A -not applicable; 95% CI -95% confidence interval; AHA -American Heart Association; EF -ejection fraction; NT-proBNP -N-terminal pro B-type natriuretic peptide; LVEF -left ventricular ejection fraction; LVEDP -left ventricular end-diastolic pressure; RR -relative risk; HR -hazard ratio; DMP -Disease Management Program; HFrEF -heart failure with reduced ejection fraction.
ambulatory care after hospital discharge, compared to only 60% among those discharged from the internal medicine ward. In our program, all patients were educated about the importance of post-discharge ambulatory visits and were given individual treatment plans. This strategy proved to be effective, with 72% of patients fulfilling visits in primary care and 30% visiting a cardiologist within 7 days of discharge.
The results of our study showed that patients undergoing any kind of education before participating in the program and patients hospitalized due to HF many times have higher initial knowledge of HF and obtained higher tests scores than the patients who had not been previously educated or hospitalized due to HF. It suggests that patients build their disease awareness from multiple educational sources and learn through their own experience during hospitalizations. 46 Although 68% of patients recruited to the study had history of HFrEF for more than 1 year and 72% had been hospitalized for HF decompensation at least once in the previous year, only 25% of participants declared being educated by a healthcare provider prior to the program. According to the participants, the cardiologist (78%), nurses (11%) and primary care physicians (11%) were the helthcare professionals who most frequently delivered disease education. This indicates that currently in Poland, there is no structured approach to health education for HF patients.

Limitations
Some important limitations of the "The Weak Heart" program have to be acknowledged. Firstly, this program had quasi-experimental, non-randomized design, without an appropriate control group, with short observation period and relatively small sample of patients. Secondly, the cohort recruited was relatively young, had a higher education level, lived with family, and the majority lived in the city. However, these factors had a limited impact on the effectiveness of the proposed program. The multivariable analysis, the results of which were presented elsewhere, 46 has shown that only age may affect self-care behaviors, but not the level of HF knowledge. Lastly, only patients with HFrEF hospitalized with ADHF were included in the study. All these factors suggest that those patients may present a higher level of health literacy and initial disease knowledge and may be significantly different from "an average patient" in routine practice. The other important limitations are the utilization of unstandardized HF knowledge questionnaire and short follow-up period. Finally, limitations resulting from the design of the project including small group size and the lack of longer-term, longitudinal data precludes a comment regarding the impact of investigated intervention on clinical outcomes, only allowing to draw general conclusions about the short-term effect of the tested model on the level of HF knowledge and self-care behaviors in the studied population of HFrEF patients hospitalized due to decompensation.

Conclusions
The HF knowledge and self-care behaviors among patients with HFrEF can be improved by introducing a structured, nurse-led educational programs to clinical practice. "The Weak Heart" educational model created based on HF guidelines recommendations proved to be effective in enhancing the level of HF knowledge and self-care behaviors among patients with HFrEF hospitalized with ADHF. The time spent in hospital should be used to prepare patients for challenges of post-discharge "vulnerable phase" by providing a proper training on self-care skills delivered by certified nurses.