International Journal of Nursing Studies 70 (2017) 1726

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

The effect on patient outcomes of a nursing care and follow-up program

for patients with heart failure: A randomized controlled trial
Dilek Sezgina,* , Hatice Merta , Ebru zpelitb , Bahri Akdenizb
a
Department of Internal Medicine Nursing, Dokuz Eyll University Faculty of Nursing, Inciralti, Izmir, Turkey
b _
Department of Cardiology, Faculty of Medicine, Dokuz Eyll University, Inciralt, _
Izmir, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Background: Heart failure is associated with exacerbated symptoms such as dyspnea and edema and
Received 17 February 2016 results in frequent hospitalization and a poor quality of life. With the adoption of a comprehensive
Received in revised form 6 February 2017 nursing care and follow-up program, patients with heart failure may exhibit improvements in their self-
Accepted 9 February 2017
care capabilities and their hospitalizations may be reduced.
Objective: The purpose of this study was to examine the effect of a nursing care and follow-up program for
Keywords: patients with heart failure on self-care, quality of life, and rehospitalization.
Heart failure
Design and setting: This research was conducted as a single-center, single-blind, randomized controlled
Self-care
Quality of life
study at the heart failure outpatient clinic of a university hospital in Turkey.
Hospitalization Participants: A total of 90 patients with heart failure were randomly assigned into either the specialized
Nursing nursing care group (n = 45) or the control group (n = 45).
Randomized controlled trial Methods: The nursing care and follow-up program applied in the intervention group was based on the
Theory of Heart Failure Self-care. Data were collected at the beginning of the trial, and at three and six
months after the study commenced. Self-care of the patients was assessed by the Self-Care of Heart
Failure Index. Quality of life was assessed with the Left Ventricular Dysfunction Scale. Rehospitalization
was evaluated based on information provided by the patients or by hospital records.
Results: A statistically signicant difference was found between the intervention and control group with
respect to the self-care and quality of life scores at both three and six months. While the intervention
group experienced fewer rehospitalizations at three months, no signicant differences were found at six
months.
Conclusion: The results obtained in this study show that the nursing care and follow-up program
implemented for patients with heart failure improved self-care and quality of life. Although there were
no signicant differences between the groups at six months, fewer rehospitalizations in the intervention
group was considered to be an important result.
2017 Elsevier Ltd. All rights reserved.

What is already known about the topic?
 Patients with heart failure are often unsuccessful at adequately
performing self-care.
 Rehospitalization in patients with heart failure are high due to
worsening of symptoms.
 It has been reported that education initiatives increase the level
of patient knowledge, but are not effective in promoting self-
care, improving quality of life, or reducing rehospitalization.
What does this paper add
 Nursing care and the follow-up program improves the self-care
of patients.
 Nursing care and the follow-up program have improved the
quality of life of patients.
 Nursing care and the follow-up program have reduced the
rehospitalization of patients by the third month.
 The present study demonstrates that the Theory of Heart Failure
Self-Care could be implemented in Turkey.

* Corresponding author at: Dokuz Eyll University Faculty of Nursing, Depart-

ment of Internal Medicine Nursing, 35340, Inciralt, Izmir, Turkey.
E-mail addresses: dileksezginn@hotmail.com (D. Sezgin),
mertbuldan@gmail.com (H. Mert), ebru.ozpelit@gmail.com (E. zpelit),
bahri.akdeniz@deu.edu.tr (B. Akdeniz).
1. Introduction
Heart failure is an important health problem that is common in
Turkey and the world. According to the statistics reported by the

http://dx.doi.org/10.1016/j.ijnurstu.2017.02.013
0020-7489/ 2017 Elsevier Ltd. All rights reserved.
18 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726
American Heart Association in 2015, there are about 5.7 million
patients with heart failure in the US, and 870.000 new patients
diagnosed annually. There are reportedly 15 million and 2.4 million
patients with heart failure in the Europe and Turkey, respectively
(Mozaffarian et al., 2015; Stromberg and Dickstein, 2008;
Degertekin et al., 2012).
Patients suffering from heart failure frequently experience
symptoms that have an impact on their functional capacities and
quality of life, leading to hospitalization (Dickstein et al., 2008;
Rodriquez-Artalejo et al., 2006; Tuppin et al., 2014; Zaya et al.,
2012; Karaca and Mert, 2011). It was determined that 30%56.6% of
patients with heart failure are rehospitalized within the rst three
months (Proctor et al., 2000; Esquivel and Dracup, 2007; Schwarz
and Elman, 2003; Polanczyk, et al., 2001; Babayan et al., 2003). It is
therefore important to develop self-care behavior in individuals
suffering from heart failure to ensure positive health outcomes and
prevent incidents of rehospitalization (Artinian et al., 2002).
Self-care involves a process of maintaining physiological
stability by monitoring symptoms, adhering to the treatment
regimen (self-care maintenance), as well as promptly identifying
and responding to symptoms (self-care management) (Riegel and
Dickson, 2008). However, patients with heart failure experience
great difculty with self-care (Dickstein et al., 2008). Dickson et al.
(2008) reported that patients with heart failure do not have a
sufcient capability for self-care; 61% of them are capable of
maintaining adequate self-care, and 44% are capable of maintain-
ing sufcient self-care management. Lee et al. (2015) claimed that
self-care management could be enhanced if patients with heart
failure were able to monitor their symptoms on a regular basis, and
that their rehospitalization rates could be reduced as the
management of their self-care improved. Sahebi et al. (2015)
reported that patients with low scores from self-care maintenance
and self-condence have a higher rate of rehospitalization. Buck
et al. (2015) addressed the difculties experienced by patients with
heart failure at maintaining their self-care as their quality of life
decreases and their rate of rehospitalization increases. To maintain
self-care at an adequate level, patients require specialized
knowledge, skills, and nursing care (Jaarsma et al., 1998).
Studies of heart failure report that educational and follow-up
programs conducted under the supervision of nurses improve self-
care behavior in patients (Brandon et al., 2009; Evangelista et al.,
2015; Jaarsma et al., 2000; Smith et al., 2015), their ability to
perform their own follow-up and adapt to treatment (Boren et al.,
2009; Sisk et al., 2006), their quality of life (Brandon et al., 2009;
Evangelista et al., 2015), their knowledge of their disease (Boren
et al., 2009; Smith et al., 2015), and reduce the incidence of
rehospitalization (Agrinier et al., 2013; Jaarsma et al., 2008).
Similar studies from Turkey reported that patient quality of life
was low (Demir and nsar, 2011; Efe and Olgun, 2011), and that
patient rehospitalization was high. Additionally, Karaca and Mert
(2011) reported that almost half of the patients were rehospi-
talized within the rst three months. To our knowledge, there are
no studies concerning the self-care of patients with heart failure in
Turkey. Therefore, Sezgin and Mert (2015) conducted a qualitative
study to evaluate the self-care management status of patients with
heart failure, which constitutes the rst stage of the project. In the
qualitative study, it was determined that patients with heart
failure were not knowledgeable about disease management,
awareness of symptoms and signicance of disease, and they
did not demonstrate self-condence regarding disease manage-
ment.
In developed countries, specialized clinics and outpatient
clinics have been established to treat heart failure, and specialized
nurses have been trained to work in this area. Patients are
followed-up after discharge, and individuals are provided with
education and consulting services (Chriss et al., 2004; Sisk et al.,
2006). In Turkey, however, there is a limited number of specialized
clinics and outpatient clinics for heart failure, and there are few
nurses and health experts for this condition. For this reason, there
is a need to develop programs to provide patients diagnosed with
heart failure with education and consulting services at clinics and
outpatient clinics and to ensure that such programs are made
widely accessible.
2. Objective
The purpose of this study was to examine the effect of a nursing
care and follow-up program for patients with heart failure on self-
care, quality of life, and rehospitalization.
2.1. Conceptual framework of the research
This study beneted from the Theory of Heart Failure Self-Care.
The Theory of Heart Failure Self-Care is categorized as a situation-
specic theory. Key concepts in the conceptual model are self-care
maintenance and self-care management. (Riegel and Dickson,
2008).
Self-care maintenance is described as a behavior used to
maintain a physiological status, such as the monitoring of
symptoms and adherence to treatment (Riegel and Dickson, 2008).
Self-care management indicates the decision-making respon-
sibility of patients when symptoms arise. Self-care management is
an active and planned process in taking the health status of heart
failure patients under control during symptomatic heart failure.
Self-condence is not a basic component of self-care and it is an
assistant or mediator of maintenance of self-care and self-care
results (Riegel and Dickson, 2008).
To ensure the maintenance of self-care of patients with heart
failure successfully, the nursing care and follow-up program was
organized to ensure that it covers the stages of theory of heart
failure self-care in this study. The implementation of the Theory of
Heart Failure Self-Care was performed as seen in Fig. 1.
3. Methods
3.1. Design
The research was conducted as a single-center, single-blind,
randomized controlled study from August 2012 to February 2014 at
the heart failure outpatient clinic of a university hospital in Turkey.
3.2. Study participants
The study sample comprised of individuals: 18 years of age and
older; functionally classied as NYHA II or NYHA III; literate; able
to speak and understand Turkish; person, place, time, and situation
oriented; and willing to participate in the study. Individuals who
had undergone by-pass surgery in the past six months, those with
severe kidney failure that necessitated dialysis, cancer patients
receiving chemotherapy or radiotherapy, COPD patients needing
ventilation, persons with cerebrovascular or rheumatoid arthritis
severe enough to affect self-care, and patients with impaired vision
or hearing were excluded from the study. The sample size was
calculated on the NCSS-PASS software program based on the self-
care scale's third- and sixth-month data (10.3  2.8) and
(11.2  3.1), respectively; a power of 80%; and a 95% condence
interval with a margin of error of 0.05, as revealed in the article by
Jaarsma et al. (2000). The estimated sample needed was 82, with
41 each in the intervention and control groups. To account for an
anticipated 10% attrition rates, eight additional participants (four
in each group) were recruited. The ninety patients (45 in the
intervention group and 45 in the control group) were recruited and
 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726 19

Fig. 1. The Implementation of the Theory of Heart Failure Self-Care.

consented. During the study, in the intervention group one patient
died, one patient could not be reached, and one patient developed
neurological problems; whereas in the control group, one patient
was lost due to death (Fig. 2). A total of 86 (95.5%) patients
completed all study time points.
In the present study, the alpha reliability level was calculated
based on the power of the test and its effect size, mean self-care
index and quality of life scores, 95%, n = 90, and a multi-
dimensional variance analysis for repeated measurements.
According to the power calculation, it was determined that the
power and effect size of the research were sufcient.
3.3. Randomization
The random number table was used as a simple randomization
method to recruit patients into the intervention and control groups
that were formed on the basis of the study inclusion and exclusion
criteria (Akgl, 2005). The list of patients to be followed was not
ready since heart failure outpatient clinic was newly opened on the
date of data collection. Patient list was created as patients were
being accepted to the outpatient clinic. Therefore, simple
randomization was performed and intervention and control
groups were created. The distribution of the study sample by
intervention and control groups is presented in Fig. 2.
3.4. Intervention
3.4.1. Interventions: control group
The patients in the control group received standard care at the
heart failure outpatient clinic. The patients were given a physical
examination by a doctor, after which their medication was
prescribed, and their outpatient clinic follow-up appointments
were scheduled. There was no handout in the outpatient clinic but

Fig. 2. Distribution of the Study Sample by Intervention and Control Groups.

20 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726
basic education was provided. The nurse-researcher answered
patients questions.
3.4.2. Interventions: intervention group
The patients in the study's intervention group were supplied
with an educational booklet based on the theory of heart failure
self-care and a daily follow-up chart on which they were expected
to record their weight, edema status, blood pressure, pulse, any
extra medications taken (e.g., diuretics), and other notes on a daily
basis. In addition, they were also provided with a magnet-held set
of instructions for factors that they should pay attention to in their
daily lives, regarding situations for which they need to visit the
outpatient clinic for a check-up or to the emergency room. The
subjects were also given magnet-held pens to record their entries.
Patients were asked to attach the magnet to their refrigerator so
that they could easily conduct daily follow-up and they would have
a reminder cue. After the baseline data of the patients in the
intervention group had been taken, the nurse researcher followed
them up with phone calls made every two weeks for a six-month
period. Additionally, the patients were assessed by the nurse
researcher in charge of the heart failure outpatient clinic before the
intervention, and after the rst, third, and sixth months or more
frequently if needed. The nurse researcher in charge of the
outpatient clinic conducted a physical examination, provided
individual education, introduced the educational booklet, diary,
magnet, and taught each patient how to perform daily monitoring
(e.g., observing edema, counting pulse, and following up on
weight). The educational intervention was tailored to adjust the
prescribed medications according to the individual's daily lifestyle,
evaluated the daily data recorded in the diary, and assessed the
patient's life at home. Patients were asked to bring their magnet-
shaped training materials when they would come to the outpatient
clinic. Their situation of symptoms such as edema, blood pressure,
taking extra diuretics and exercise levels at home were checked
and their domestic life was evaluated along with them. Moreover,
the nurse researchers reviewed the patient's complaints, what the
patients did when the symptoms were experienced, whether or
not the patients actions were of any benet, whether or not the
patient had been hospitalized, or had presented to the emergency
room.
With the supplied individual education and educational
booklet, we tried to increase, the patients awareness and
knowledge. With the educational booklet designed by the nurse
researcher, a magnet supported the educational material and a
telephone follow-up, ensuring the monitoring of individual
symptoms, treatment adherence, and recognition of symptoms
was attempted to develop self-care maintenance. Outpatient clinic
follow-up and counseling also facilitated self-care management
(Fig. 1).
3.5. Outcome measures
The patient information form, The Self-Care of Heart Failure
Index, and a quality of life scale (The Left Ventricular Dysfunction
Scale) were used in the evaluation of this study.
3.5.1. Primary outcomes
3.5.1.1. Self-Care of heart failure index. Self-care of the patients was
assessed by the Self-Care of Heart Failure Index (SCHFI V6.2)
(Riegel et al., 2009). The index has 22 items, which are scored to
form three scales: 1) self-care maintenance (adherence to
treatment regimens and symptom monitoring behaviors); 2)
self-care management (ability to recognize changes in symptoms,
evaluating the importance of that change, implementing remedies,
and evaluating treatment effectiveness); and 3) self-care
condence (perceived ability to engage in self-care). Each of the
three scales use a 4-point likert scale with a standardized score
from 0 to 100; higher scores indicate a higher contribution to self-
care. Scale scores 70 are considered to reect adequate self-care.
Internal consistency of the self-care scales; self-care maintenance
(Cronbachs a = 0.55), self-care management (Cronbachs a = 0.59)
and self-care condence (Cronbachs a = 0.82) was found by the
instrument authors (Riegel and Dickson, 2008; Vellone et al., 2015;
Buck et al., 2015).
The Turkish validity and reliability study for this 22-item index,
revised in 2009, was carried out in 2013 by Mert et al. (2013). This
study used the Self-care of Heart Failure Index, the validity and
reliability study of which was completed by Mert et al. (2013)
(Cronbachs a values of 0.79, 0.63 and 0.85). The internal
consistency coefcients of the Self-care Index in this study were
found to be 0.80, 0.77 and 0.75, respectively.
3.5.2. Secondary outcomes
3.5.2.1. Left ventricular dysfunction scale (Quality of life). Quality of
life was assessed via the Left Ventricular Dysfunction Scale (LVD-
36). The Left Ventricular Dysfunction (LVD) scale developed by
OLeary and Jones (2000) to measure the impact of left ventricular
dysfunction on the daily lives and wellness of patients suffering
from heart failure. The Turkish validity and reliability study for the
LVD-36 Scale was carried out by zer and Argon (2005) (Cronbach
alpha=0.87). The internal consistency coefcient of the LVD Scale in
this study was found to be 0.94.
The scale consists of 36 statements designed to determine
issues arising due to heart failure. The statements are presented to
patients with the choice to select true or false as a response. The
right answers are added and expressed as a percentage of all the
true statements. Possible scores on the scale range from 0 to 100, in
which a score of 100 signies the worse score, and 0 points the best
score.
3.5.2.2. Rehospitalization. If a participant was re-admitted to the
hospital in a period of three to six months following discharge due
to a decompensation of heart failure is considered to be an instance
of rehospitalization. Nurse researcher phoned the participants in
the intervention group to collect data regarding their
hospitalization and outpatient clinic check-ups, or otherwise
consulted the hospital les. Data on the individuals in the control
group were collected upon their return to the outpatient clinic for
their follow-up in the third and sixth month, or otherwise pulled
from their hospital les.
3.6. Ethical considerations
Permission for the implementation of the research was
obtained from the Dokuz Eyll University Medical School Hospital,
where the study was conducted (B.30.2.DE.0.H1.70.83-443). The
Dokuz Eyll University Non-invasive Clinical Trials Evaluation
Committee granted ethics board approval on July 28, 2010, under
Decision No. 2010/08-13. The purpose of the research was
explained to the participants, and all individuals that voluntarily
accepted to participate were recruited to the study. A written letter
of consent was also obtained from the research participants.
Upon completion of the study, the control group was given the
educational booklet, magnet-attached instructions, and the daily
follow-up chart.
3.7. Data collection
Data were collected from patients in the intervention and
control groups who had been selected in accordance with the
 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726 21

sample criteria beginning at the rst interview (baseline), then at
the third and sixth month at the heart failure outpatient clinic of a
university hospital. Nurse researcher lled out the identifying
forms of the patients with heart failure and the data for the self-
care of heart failure index and quality of life scale on the basis of the
face-to-face interviews conducted with the patients. The NYHA
staging of the sample criteria was carried out and evaluated in
collaboration with the attending cardiologist and nurse researcher.
3. Data analysis
The data were analyzed using the SPSS 15.0 (SPSS Inc., Chicago,
IL, USA) software. The characteristics of the intervention and
control groups were described using descriptive statistics. The
independent group t-test for continuous variables and a chi-square
test for categorical variables were utilized to compare the
intervention and control groups for all baseline variables. There
was no difference between groups with respect to most
demographic and illness-related characteristics. However, the
intervention group was slightly younger (60.75  11.87 to
65.86  11.09; p < 0.05). For this reason, a covariance analysis
was performed for the age variable.
The self-care, and quality of life mean scores of the intervention
and control groups were analyzed using the multivariate analysis
of variance for repeated measures. The advanced analysis assessed
the differences between the intervention and control groups by
using the independent group t-test to compare the groups, and a
one-way analysis of variance to compare the data within each
group. To determine which measure was responsible for the
difference in the intervention group, a bonferroni-adjusted
dependent group t-test was conducted. The hospitalization status
of the intervention and control groups was assessed using a chi-
square test. During the study, in the intervention group one patient
died, one patient could not be reached, and one patient developed
neurological problems; whereas in the control group, one patient
was lost due to death. An intention to treat (ITT) analysis was
performed due to the loss of data in the intervention and control
groups. It was thought that exclusion of lost data in a randomized
controlled trial might cause bias in sampling characteristics and
study results. The analyses were performed with 90 patients;
exclusion of individuals who left study was prevented in order to
protect characteristics of the sample.
4. Results
4.1. Comparison of the two groups at baseline
The distribution of the intervention and control groups'
individual, illness, and treatment-related characteristics are
presented in Table 1. The intervention and control groups were
similar in individual and illness-related characteristics (p > 0.05),
outside of age (p < 0.05). (Table 1). There were no statistically

Table 1
Distribution of the Intervention and Control Groups' Individual and Illness Related Characteristics (Baseline).

Intervention Control Homogeneity of variance

n = 45 n = 45
X  SD X  SD t p
Age 60.75  11.87 65.86  11.09 2.110 <0.05
Diagnosis duration of HF 44.93  45.06 44.11  39.45 0.092 0.927

EF (%) 30.22  7.68 30.26  7.68 0.027 0.978

Intervention n (%) Control n (%) x2 p

NYHA stage
II 34(51) 33(49) 0.809 0.500
III 11(48) 12 (52)

Gender
Female 7 (16) 14 (31) 3.043 0.081
Male 38 (84) 31 (69)

Education Status
Primary school 23 (51) 33 (73) 4.811 0.090
Secondary school 14 (31) 7 (16)
High education 8 (18) 5 (11)

Marital Status
Married 41 (91) 42 (93) 0.155 0.694
Single 4 (9) 3 (7)

Income level
Income < expense 5 (11) 5 (11)
Income = expense 34 (76) 28 (62) 2.581 0.275
Income > expense 6 (13) 12 (17)

Employment Status
Employed 10 (22) 4 (9) 2.115 0.146
Unemployed 35 (78) 41 (91)

Other chronic diseases

Yes 32 (71) 36 (80) 0.963 0.327
No 13 (29) 9 (20)

Rehospitalizations (in last one year)

Yes 25 (56) 28 (62) 0.413 0.520
No 20 (44) 17 (38)
22 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726

signicant differences between the groups in self-care scores
except for with self-care condence and the left ventricular
dysfunction scores (p > 0.05).
4.2. Impact of experimental programs on outcomes
4.2.1. Primary outcomes of self-care
While the analysis revealed no signicant differences between
the mean baseline scores in the intervention and control groups
with regard to their self-care maintenance (t = 0.093; p > 0.05);
however, there were signicant differences at the third (t = 8.080; p
< 0.001) and sixth months. (t = 8.662; p < 0.001). At follow-up, a
signicant difference was found with the self-care maintenance of
the intervention group (F = 88.401, p < 0.001), no signicant
differences were found in the measurements of the control group
(F = 0.109; p > 0.050) (Table 2). There were signicant differences in
the intervention group between baseline to the third month (t:
9.686; p < 0.001), fourth to sixth months (t: 2.782; p < 0.05), and
from baseline to six months (t: 9.695; p < 0.001) (Table 3).
While the analysis revealed no signicant differences in the
baseline mean scores between the intervention and control groups
in self-care management (t = 0.755; p > 0.05), there were statisti-
cally signicant differences at three (t = 8.038; p < 0.001) and six
(t = 8.245; p < 0.001) months. While a signicant difference was
found with time at follow-up of the intervention group (F = 84.929;
p < 0.001), no signicant differences were found in the measure-
ments of the control group (F = 1.166; p > 0.05) (Table 2). The
analysis showed signicant differences between the baseline and
third month (t: 9.728; p < 0.001), fourth to sixth months (t: 3.472;
p < 0.05), and baseline to the sixth month (t: 9.760; p < 0.001)
(Table 3).
While the analysis revealed no signicant difference between
the baseline mean scores of the intervention and control groups in
self-care condence (t = 2.251; p > 0.05), there were statistically
signicant differences at the third (t = 5.483; p < 0.001) and sixth
(t = 6.354; p < 0.001) months (Table 2). While a signicant statisti-
cal difference was found with time in the intervention group
(F = 65.330; p < 0.001), no statistically signicant differences were
found in the measurements of the control group (F = 0.333;
p > 0.05) (Table 2). In the intervention group, signicant differences
were found between the baseline and the third month (t: 8.097;
p < 0.001), fourth to sixth months (t: 3.748; p < 0.001), and
baseline to the sixth month (t: 8.417; p < 0.001) (Table 3).
4.2.2. Secondary outcomes of the quality of life and rehospitalization
4.2.2.1. Examining the quality of life of patients with heart
failure. While the analysis revealed no signicant difference
between the baseline mean scores of the intervention and control
groups in the Left Ventricular Dysfunction Scale (t = 1.173; p > 0.05),
there were statistically signicant differences at the third
(t = 4.742; p < 0.001) and sixth (t = 5.131; p < 0.001) months.
While a signicant statistical difference was found with time in
the follow-up of the intervention group (F = 47.647; p < 0.001), no
statistically signicant differences were found in the
measurements of the control group (F = 0.362; p > 0.05)
(Table 4). In the intervention group, signicant differences were
found between the baseline and third month (t: 7.101; p < 0.001)
and baseline to the sixth month (t: 7.327; p < 0.001); no signicant
differences were found between the fourth to sixth month (t:
2.470; p > 0.0.05) (Table 5).
4.2.2.2. Examining the hospitalization status of individuals with heart
failure. When the intervention and control groups were evaluated
in terms of their hospitalization due to the decompensation of
heart failure, it was found that there were signicant differences in
hospitalization status from baseline to the third month (x2: 9.680;
p < 0.05) but there was no signicance from the fourth to sixth
months (x2: 3.850; p = 0.05) (Table 6).
5. Discussion
The results of the implementation of the nursing care and
follow-up program for patients with heart failure showed that the
intervention group experienced more improvement in self-care
and quality of life. Moreover, it achieved a reduction in the
rehospitalization (at the third month) compared to the control
group (Tables 26). In comparing the self-care maintenance, self-
care management and self-care condence of the intervention and
control groups, it was found that there were statistically signicant
differences between both the groups, and within the intervention
group over time that favored the intervention (Table 2).
Self-care maintenance comprises the monitoring of symptoms,
adaptation to treatment, and learning to recognize symptoms
(Lainscak et al., 2011; Riegel et al., 2009). It has been stated that
recognizing symptoms is an important step in the management of
the self-care of heart failure (Riegel and Dickson, 2008). Studies

Table 2
Mean Scores of Self-Care of Heart Failure Index Subscale by Group and Time.

Time Group Baseline 3rd month 6th month F p 95% CI

Self-care maintenance X  SD X  SD X  SD
Intervention 40,73  10.65 68,43  19.14 71,54  19.50 88.401 <0.001 47.635 53.096
Control 40,51  11.91 40,73  12.74 40,21  14.43 0.109 0.897
t 0 0.093 8.080 8.662
p 0.926 <0.001 <0.001

Self-care management
Intervention 24.55 16.88 56.66  16.58 63.33  21.37 84.929 <0.001 34.872 41.313
Control 27.22  16.63 27.77  17.50 29.00  17.98 1.166 0.316
t 0.755 8.038 8.245
p 0.452 <0.001 <0.001

Self-care condence
Intervention 34.71  21.92 64.49  22.31 69.68  22.54 65.330 <0.001 46.244 53.135
Control 43.61  14.89 53.56  21.78 42.99  16.90 0.333 0.718
t 2.251 5.483 6.354
p <0.05 <0.001 <0.001

CI = condence interval.
 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726 23

Table 3
Comparison of Self-Care of Heart Failure Index Subscale Mean Scores of Intervention Group in Terms of Time (further analysis).

Time Group Self-care maintenance Self-care management Self-care condence

X  SD X  SD X  SD
Baseline 3rd month 40,73  10.65 24.55 16.88 34.71  21.92
68,43  19.14 56.66  16.58 64.49  22.31
t 9.686 9.728 8.097
p p < 0.001 p < 0.001 p < 0.001
4th 6th month 68,43  19.14 56.66  16.58 64.49  22.31
71,54  19.50 63.33  21.37 69.68  22.54
t 2.782 3.472 3.748
p p < 0.05 p < 0.05 p < 0.001

Baseline-6th month 40,73  10.65 24.55 16.88 34.71  21.92

71,54  19.50 63.33  21.37 69.68  22.54
t 9.695 9.760 8.417
p p < 0.001 p < 0.001 p < 0.001

Table 4
Analysis of Mean Scores on Left Ventricular Dysfunction Scale by Group and Time.

Time Group Baseline 3rd month 6th month F p 95% CI

X  SD X  SD X  SD
Intervention 55.67  20.60 40.92  22.50 38.33  23.65 47.647 <0.001 48.954 57.240
Control 60.86  21.32 61.66  18.82 61.11  18.08 0.362 0.697
t 1.173 4.742 5.131
p 0.244 <0.001 <0.001

CI = condence interval.

Tung et al., 2012). In their qualitative study, Sezgin and Mert (2015)
Table 5
stated that heart failure patients' lack of knowledge concerning
Comparison of Left Ventricular Dysfunction Scale Mean Scores of Intervention
Group in Terms of Time (further analysis). management of their disease was an obstacle factor in self-care.
The individualized education provided to the intervention
Time Group Left Ventricular Dysfunction Scale
group in our study in conjunction with the educational booklet, the
X  SD
magnet-enhanced instruction sheet, daily monitoring charts, and
Baseline 3rd month 55.67  20.60 40.92  22.50
the outpatient clinics nursing follow-up increased the levels of
t 7.101
p p < 0.001 knowledge and may have also enhanced patients' awareness of
4th 6th month 40.92  22.50 38.33  23.65 changes in their bodies. Moreover, it increased their ability to
t 7.327 recognize symptoms and adapt themselves to the prescribed
p p < 0.001 treatment. Additionally, when the patients in the intervention
Baseline-6th month 55.67  20.60 38.33  23.65
group came to the outpatient clinic for follow-up, a large
t 2.470
p p > 0.05 percentage stated that they had devised a method of reminding
themselves when to take their medications, they made use of the
knowledge imparted in the education booklets, and had become
aware of the drug-related side effects of the medications they were
Table 6
Comparison of Hospitalization Status of Intervention and Control Groups. taking. In addition, the patients were able to ask for adjustments in
their prescriptions. Therefore, the intervention had an impact on
Baseline 3rd month 4th 6th month self-care maintenance.
Intervention Control Intervention Control For patients with heart failure to be able to achieve self-care
n (%) n (%) n (%) n (%) management, they must not only succeed during the self-care
Rehospitalization maintenance step but also acquire the skills that will enable them
Yes 2 (4) 13 (29) 7 (16) 15 (33) to evaluate the symptoms they are experiencing, implement the
No 43 (96) 32 (71) 38 (84) 30 (67)
appropriate intervention, and assess the impact of the intervention
x2: 9.680 x2: 3.850
p < 0.05 p = 0.050 on their symptoms (Chriss et al., 2004; Riegel et al., 2015). Self-care
management also encompasses the individual's process of
decision-making. For this reason, patients must be able to correctly
interpret symptoms and display the knowledge and skills required
have reported that patients with heart failure lack adequate to begin an intervention (Riegel et al., 2015). Studies have reported
knowledge about how to manage their illness (Riegel and Carlson, that nursing interventions introduced to patients with heart failure
2002; Siabani et al., 2013), and that educational interventions improve self-care management skills (Clark et al., 2015; Mrtens-
(Chriss et al., 2004; Lainscak et al., 2011; Rockwell and Riegel, son et al., 2009; Sisk et al., 2006; Smith et al., 2015; Strmberg et al.,
2001), telephone follow-ups and the use of diaries (Brandon et al., 2003). In our study, individuals in the intervention group were able
2009; White, et al., 2010) increase the levels of knowledge and to note changes they experienced in their diaries, and discuss these
symptom recognition, allowing individuals to achieve improve- changes with the nurse researcher at follow-up or outpatient clinic
ments in self-care (Chiarana et al., 2009; Clark et al., 2015; checkups. The patients in the intervention group made it known
Mrtensson et al., 2009; Seto et al., 2011; Smeulders et al., 2010; that the guidance they received regarding symptoms and the
24 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726
actions to take when the symptoms were experienced were
benecial. Therefore, the intervention implemented in this study
had an impact on improving patient self-care management.
When patients with heart failure can successfully achieve the
steps required for self-care maintenance and management, their
self-condence concerning self-care is heightened accordingly.
This is because when patients can make the early identication of
their symptoms and implement the appropriate intervention, they
realize that they experience fewer symptoms. Moreover, because
they then believe they can manage their illness, their self-
condence also improves (Riegel and Dickson, 2008; Riegel et al.,
2015). Since the self-care maintenance and management skills of
the patients in the study had improved, improvement in self-care
condence is an expected consequence. In contrast, Buck et al.
(2015) and Vellone et al. (2015) reported that self-condence was
effective for the maintenance and management of self-care.
Accordingly, there could be a reciprocal correlation between
self-condence in the maintenance of self-care and maintenance
and management.
In comparing the left ventricular dysfunction scale scores of the
intervention and control groups, it was found that there were
statistically signicant differences both between the groups and
within the intervention group with time (Tables 45). Studies have
shown that education, counseling interventions (Chu et al., 2014;
Efe and Olgun, 2011; Grady et al., 2014), and follow-ups by a
multidisciplinary team (Goodman et al., 2013) implemented in the
case of patients with heart failure have a positive impact on the
quality of life. A study conducted by Kutzleb and Reiner (2006)
found that nurse-led intervention improved the quality of life.
Another study conducted by Evangelista et al. (2015) found that
patient self-care and quality of life were improved with nurse-led
intervention.
The results of our study are consistent with the literature. The
level of quality of life of the patients with heart failure in the study
demonstrated improvements in the third and sixth months. It
might be that individuals who were able to make an early
identication of their symptoms and with the interventions they
implemented, were able to prevent the decompensation of heart
failure. The patients succeeded to continue their daily activities of
life and take part in social events, which made them feel better and
more self-condent. The fact that the patients in the intervention
group did not need help in going to the outpatient clinic for their
doctor's visits, to go grocery shopping, or take care of their other
needs during the period of their follow-ups. This revealed to us that
they were able to spend time with their families and friends, and
enjoy a heightened quality of life, supporting our premise. One
study dened the quality of life in the case of patients with heart
failure as both the absence of symptoms, as well as socializing,
continuing to work, and maintaining daily activities without
outside help (Heo et al., 2009).
When the rehospitalization status of the patients in the
intervention and control groups in the study was compared, it
was observed that while there were statistically signicant differ-
ences between the intervention and control groups from the baseline
to the third month (p < 0.05), there was no signicance from the
fourth to sixth months (p > 0.05) (Table 6). When it is considered that
of the patients with heart failure, 30%-56.6% were rehospitalized
within the rst three months after discharge (Babayan et al., 2003;
Schwarz and Elman, 2003; Polanczyk et al., 2001), the intervention
implemented in our study can be considered to have had a signicant
impact on rehospitalization.
Agrinier et al. (2013) examined the effect of the self-care
management program given to patients with heart failure on
hospitalization frequencies, and reported a reduction in the
hospitalization frequency as a result of the program. In their
meta-regression analysis, Sochalski et al. (2009) reviewed the
impact of heart failure management programs on preventing
hospitalization, and concluded that face-to-face interviews and a
multidisciplinary approach were effective in reducing hospitaliza-
tion rates.
From the fourth to sixth month of the current study, 15.6% of the
patients in the intervention group and 33% in the control group
were rehospitalized. When it is considered that other studies
reect a hospitalization rate of 23%50% during the rst six months
(Krumholz et al., 2000; Rodriquez-Artalejo et al., 2006), this result
can be considered clinically meaningful. Moreover, the lower rate
of hospitalization among the individuals in the intervention group
in the sixth month is of particular importance.
It may have been that the hospitalization rate was diminished
because of the improvement in the patients' self-care habits. Other
studies have also found that self-care impacts hospitalization rates.
The study by Lee et al. (2015) reports that when patients with heart
failure can regularly monitor their symptoms, self-care manage-
ment is improved, with which individuals may consequently
achieve lower hospitalization rates.
When patients learn to recognize their symptoms and monitor
themselves on a regular basis, their ability to achieve an early
diagnosis is facilitated, and they can take precautions as soon as
symptoms begin, and before the decompensation of heart failure is
experienced.
The number heart failure nurses in outpatient clinics providing
care for heart failure patients in Turkey is quite limited. The
outpatient clinic where the study was conducted did not have
heart failure nurses. As a result of this study, it was understood that
outpatient clinic should have heart failure nurses. Works are in
progress for inclusion of heart failure nurses into the outpatient
clinic and maintaining the program. Studies to be conducted
within this scope might light the way for construction of
outpatient clinics in Turkey and other countries. Different
follow-up methods can be developed in outpatient clinics by
basing on the study results.
6. Limitations
Our study had several limitations. The research was conducted
at a single-center. The study sample represents patients exhibiting
the characteristics dened as heart failure in the sample. This study
cannot be generalized for patients at stage of NYHA IV. The follow-
up duration was only 6 months. A longitudinal follow-up of
initiatives results as of diagnoses could be the next step after this
research. Patients in intervention and control groups might have
had interactions in the waiting room when they visited outpatient
clinic for controlling.
7. Conclusions
This is the rst study of its kind in Turkey and conrms the value
of nurse-driven heart failure education programs that signicantly
reduce hospital readmissions and improve self-care and quality of
life. Conducting multi-centered studies on larger sampling groups
and implementing a cost analysis would allow for the expansion of
outpatient clinics operated by nurses.
Implications for nursing
 The following recommendations should be considered: nurses
specialized in cardiology should be employed at outpatient
cardiology clinics to provide training and achieve the monitoring
of patients with heart failure;
 Awareness should be raised among nurses regarding the
importance of recognizing and monitoring symptoms as a part
of self-care management;
 D. Sezgin et al. / International Journal of Nursing Studies 70 (2017) 1726
 Patients should be monitored at regular intervals after discharge;
 A system for counseling should be developed whereby patients
with heart failure may nd resources for when they experience
problems at home;
 Patients should be encouraged to keep diaries for purposes of
self-care management;
 Studies should be planned in the future that will include patients
categorized in the functional classication of NYHA IV.
Declaration of conicts of interests
The authors declared no potential conicts of interest with
respect to the authorship and/or publication of this article.
Funding
This study was supported by Dokuz Eyll University Research
Projects Branch Directorate under Reference No. 2012KBSAG93.
Ethical approval
Permission for the implementation of the research was
obtained from the Dokuz Eyll University Medical School Hospital,
where the study would be conducted. (B.30.2.DE.0.H1.70.83-
443). The Dokuz Eyll University Noninvasive Clinical Trials
Evaluation Committee granted ethics board approval on July 28,
2010 under Decision No. 2010/08-13.
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