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Implementation of Efficacy Enhancement Nursing Interventions with Cardiac Elders
Intervention strategies based on social cognitive theory and encompassing the bio-psycho-behavioral domains are proposed to enhance self-efficacy in men and women 65 years and older recovering from myocardial infarction and coronary artery bypass grafting. This paper describes a study in which the theory-based development of efficacy enhancement (EE) nursing interventions and their implementation and utilization with interventions from the Nursing Interventions Classification (NIC) were used with cardiac elders in the treatment group of the community-based randomized clinical trial, “Improving Health Outcomes in Unpartnered Cardiac Elders.” Advanced practice nurses (APNs) provided the nursing intervention to 110 participants (mean age = 76.2, SD = 6.0) for the first 12 weeks after discharge to home. After an initial introductory meeting in the acute-care setting, participant contacts by the APNs were made at a home visit and telephone calls at 2, 6, and 10 weeks. Results describe the number of participants receiving interventions at all contacts over 12 weeks, at specified contact points, and the intensity (nurse time) of the interventions. Verbal encouragement and mastery were EE interventions used with the greatest number of participants. Exercise promotion, energy management and active listening were NIC interventions used with the most participants. Variations in the use of interventions over 12 weeks and their intensities, suggest patterns of recovery in the elders. During rehabilitation EE interventions can be successfully implemented with men and women 65 years and older and individualized to the recovery trajectory. Nurses can integrate specific EE interventions with more general interventions from the bio-psycho-behavioral domains to enhance the recovery process for cardiac elders.
Americans are living longer, but more importantly, they are often living with chronic conditions that are the leading causes of illness and disability (Centers for Disease Control and Prevention, 2000). Managing a chronic illness, such as cardiovascular disease, in the population of men and women 65 years and older requires both illness and wellness perspectives. When members of this population participate in health-promoting activities (e.g., exercise, diet adherence, and psychosocial support) in combination with day-to-day management (e.g., medication taking, symptom control, and dealing with the emotional sequelae), they may achieve desired health benefits. Health promotion management requires changing or developing new behaviors (Lorig & Holman, 2003). Self-efficacy has been identified as a primary determinant in behavior change (Bandura, 1977, 1986, 1992, 1995).
The nation’s public health agenda, Healthy People 2010 (U.S. Department of Health and Human Services, 2000), states that to achieve health promotion and disease management, intervention must include bio-psycho-behavioral strategies. Such interventions aimed at affecting self-efficacy have been proposed as methods to assist in this process (Buselli & Stuart, 1999; Lorig & Holman, 2003). This paper discusses the development and implementation of nursing interventions selected from bio-psycho-behavioral domains for efficacy enhancement (EE) in cardiac men and women 65 years and older.
Derived from the framework of social cognitive theory, self-efficacy—the belief in one’s ability to mobilize motivation, cognitive resources, and courses of action needed to meet given situational demands—has been posited as necessary in behavioral change (Bandura, 1977, 1986, 1992, 1995). The possible predictive effect of self-efficacy on health behaviors has been examined in numerous studies, as noted in the review by Clark and Dodge (1999). A growing body of knowledge is developing out of this research that demonstrates how interventions can change self-efficacy and how those changes in self-efficacy are associated with changes in behavior and health status (Gonzales, Goeppinger, & Lorig, 1990).
Development of programs with effective intervention strategies to improve self-efficacy is currently one focus of attention in assisting people with chronic illness to achieve the best level of health (Shortridge-Baggett, 2001). For example, in a community-based program for self-management of arthritis, trained lay leaders used strategies to enhance self-efficacy (Lorig, Gonzales, & Ritter, 1999). Participants in the treatment group demonstrated improved health behaviors, health status, and self-efficacy. Researchers interpreted the data to suggest that both baseline self-efficacy and changes in self-efficacy were associated with future health status. Lev, Daley, Conner, Reith, and Fernandez (2001) conducted a randomized trial that tested a self-efficacy intervention that included educational materials and efficacy-enhancing counseling by nurses. Researchers documented increased quality of life and decreased symptoms in breast cancer patients. Resnick (1998, 2001) and Resnick and Nigg (2003) suggested that self-efficacy may be important in interventions to increase activity and exercise in older adults. Resnick (1998) tested a theory-based self-efficacy intervention in an experimental pretest-posttest design study with geriatric rehabilitation participants. The experimental group received efficacy-enhancing interventions by video and interactions with a nurse investigator. The use of efficacy enhancing interventions demonstrated that self-efficacy beliefs can be strengthened in this population and are related to increased participation in rehabilitation.
Self-efficacy has been proposed and described as a predictor or mediator to improve health outcomes in the management of cardiac disease. Carroll (1995) found support for self-efficacy expectation (described as a personal belief in one’s capability to execute particular behaviors) as a mediator between self-care agency and self-care recovery behaviors in a prospective study with coronary artery bypass graph surgery (CABG) patients. Jenkins and Gortner (1998) found strong evidence for the predictive capability of self-efficacy expectation for activity in a prospective cohort designed study with CABG patients. Perkins and Jenkins (1998), in a descriptive study of patients following percutaneous transluminal coronary angioplasty, concluded that findings of higher self-efficacy relating to higher behavior performance supported the predictive ability of self-efficacy expectation.
Changes in self-efficacy have been studied in randomized clinical trials in cardiac rehabilitation programs. Berkhuysen, Nieuwland, Buunk, Sanderman, and Rispens (1999) compared changes in self-efficacy in two exercise groups receiving different levels of exercise training in a multidisciplinary rehabilitation setting. The mixed results suggested the need to design programs that incorporate more self-efficacy theory. Carlson and colleagues (2001) tested a modified cardiac rehabilitation program based on Bandura’s self-efficacy theory and designed to enhance the patient’s confidence to engage in independent exercise. Self-efficacy was found to be a significant predictor of independent exercise. The findings supported individualization of cardiac rehabilitation programs that promote self-efficacy.
The development and detailed descriptions of efficacy enhancing nursing interventions with cardiac patients are somewhat limited. A nursing intervention based on social cognition theory designed to improve physical functioning and psychological adjustment after ICD implantation has been described (Dougherty, Johnson-Crowley, Lewis, & Thompson, 2001; Dougherty, Pyper, & Frasz, 2004). The three-part program consisted of an informational booklet, nursing telephone support using a protocol, and nurse pagers. Goals of the nursing support were to educate, enhance self-confidence, and reduce emotional arousal, such as anxiety and distress. Carroll, Robinson, Buselli, Berry, and Rankin (2001) described advanced practice nurse (APN) interventions based on social cognition theory and designed to influence self-efficacy in elders after myocardial infarction. The APN activities included patient education, validation/feedback, encouragement/support, and problem solving. Activities to enhance self-efficacy expectation for recovery behaviors were emphasized.
Gilliss, Gortner, Shinn, Sparacino, and Tompkins (1993) used a psychoeducational nursing intervention based on the self-efficacy theory of Bandura in a randomized clinical trial with cardiac surgical patients. The interventions used self-efficacy enhancement strategies and included in-hospital education, telephone follow-up after discharge for monitoring recovery, reinforcement of education, coaching toward recovery activity, and provision of reassurance. Their findings suggested that the intervention may promote self-efficacy expectancy for recovery behaviors after cardiac surgery.
Although several programs demonstrated the positive effects of self-efficacy, there remains a need for further randomized controlled research to replicate findings. The need to implement nursing interventions that have been adequately defined and detailed has been identified as important to avoid the potential for unreliability and bias in the results of randomized clinical trials (Lindsay, 2004). Whittemore and Grey (2002) emphasized the need to determine the amount and intensity of nursing time and the timing of interventions provided to contribute to the systematic development of nursing interventions. Building upon findings from a previous study, Rankin (2000) implemented a randomized clinical trial, “Improving Health Outcomes in Unpartnered Cardiac Elders” (R01NR05205), to test a collaborative APN and peer advisor (PA) intervention using self-efficacy and social support to improve physical and mental health and functioning in cardiac elders following myocardial infarction (MI) or CABG. The PA intervention has been described elsewhere (Robinson, Rankin, Arnstein, Carroll, & Traynor, 1998; Whittemore, Rankin, Callahan, Leder, & Carroll, 2000; Winder, Hiltunen, Sethares, & Butzlaff, 2004). This study explores the theory-based development of EE nursing interventions and the implementation and use of these interventions in combination with interventions from the Nursing Interventions Classification (NIC) with cardiac elders randomized to the treatment group of the study, “Improving Health Outcomes in Unpartnered Cardiac Elders.”
Development of the Efficacy Enhancement Intervention
For men and women 65 years and older with cardiac disease, improved function to enhance independence is an important outcome of recovery from MI or CABG. The interventions for this study were designed to address ways cardiac elders might increase self-efficacy or confidence to perform self-management and recovery activities. Social cognitive theory was the basis for the development of EE nursing interventions within this community-based randomized clinical trial.
According to social cognitive theory, judgments of self-efficacy are derived from principal sources of information conveyed in four manners: enactively, vicariously, socially, and physiologically (Bandura, 1992). Based on the model presented by Bandura (1977, 1986, 1992, 1995), the following four antecedents to self-efficacy were identified as foci of intervention for this study: mastery experience, vicarious experience, verbal encouragement, and reinterpretation of symptoms. Definitions used in this study for participant achievements were as follows:
The research team identified and agreed upon specific activities for the interventions pulled from case examples and the literature. Examples of the APN activities for each EE intervention with the cardiac elders are shown in Figure 1.
To provide a bio-psycho-behavioral approach and to allow for individualized interventions, the research team also identified interventions from the Nursing Interventions Classification (NIC; McCloskey & Bulecheck, 2000) that were important for recovery in cardiac elders. Thirty-one interventions from NIC were selected for this study and represented five domains in the NIC taxonomy: basic physiological, behavioral, safety, family, and health system. A cardiac clinical nurse specialist reviewed the interventions for completeness and appropriateness for the patient population. The NIC definitions and intervention descriptions (McCloskey & Bulecheck) were available to the APN interventionists.
Implementation of the Intervention
Two APNs who had expertise with elders and cardiac patients provided the intervention. Their focus was to enhance the self-efficacy of unpartnered elders after an MI or CABG who were assigned to the treatment group of the study. As the study progressed, the APNs maintained frequent contact to standardize delivery and documentation of the intervention.
After a participant was randomized to the treatment group, the APN met the participant in the acute-care hospital setting and once again at home within 7 days after discharge. The face-to-face contact enhanced personal connectedness and relationship building; subsequent contact with the participant was designed to be by telephone. During initial meetings, the APN explained that her role was to provide support, information, and guidance during recovery through further telephone calls and contacts. The participant was encouraged to describe his or her cardiac story, plans, and goals.
Specific contacts determined by the protocol were a home visit within 1 week of discharge and telephone calls at 2, 6, and 10 weeks after discharge. Any additional contacts were individualized according to the course of the participant’s recovery on an as needed basis. If the participant was discharged to a rehabilitation facility for more than 2 weeks, the APN visited the facility to maintain the relationship and provide support and encouragement. Contact with participants was more frequent if there was frailty, worsening symptoms, or other identified needs. Follow-up by mail with educational information was provided on an individualized basis. Contact by e-mail was also an option for participants and APNs. The total treatment time was 12 weeks after discharge to home.
With each contact, the APN provided support through active listening and guidance. Initial contacts included assessment of symptom management, safety, and resource and learning needs, and identification of strengths. As the participant progressed through recovery, the APN assisted the participant identifing and setting goals for a successful recovery and healthy lifestyle. The goal of the self-efficacy enhancement intervention was to strengthen a patients’ belief and confidence in their ability to have a successful recovery. Interventions from NIC provided treatment and recovery support, particularly in the physical and behavioral domains.
Participants in the study were admitted to the cardiac service of five academic medical centers in Massachusetts and California. Adult patients who had a diagnosis of MI or CABG were targeted. Inclusion criteria for this study were men and women 65 years or older who were unpartnered (widowed, divorced, single), were able to speak and read English, and had access to a telephone. This cohort comprised 110 participants who were randomized to the treatment group of the larger clinical trial (n = 248). Participants were included in this analysis if they received a home visit by an APN. Because of participant withdrawal from the study or death, 109 participants were included in this analysis at 6 weeks and 106 participants at 12 weeks. There were 71 (65%) women and 39 (35%) men in the group; the mean age was 76.2 (SD = 6.0) years. CABG procedures accounted for 63% of the participants, and 37% had had an MI. The majority of participants (70%) were widowed. Seventy-nine percent lived alone; 18% lived with family or friends; and the remaining lived in assisted-living or other settings. Most of the participants were Caucasian (90%), and 76% lived on the east coast of the United States.
Data Collection and Analysis
APN interventions were recorded on an investigator-developed data collection tool. This grid format listed each of the NIC and EE interventions and allowed the APNs to record all interventions used at each contact by date and type of contact (telephone call, home, hospital or rehabilitation facility visit). Each intervention was coded for intensity, or time spent, on a scale of 1–3. One represented a minor topic or less than 25% of time; two represented a substantial topic, or moderate amount of time; and three represented a major topic or majority of time. The grid format allowed for easy documentation and data entry.
Data recorded were analyzed by using descriptive statistics. The number of participants receiving each of the interventions was examined in the following two ways: overall frequency of interventions for all contacts between the APN and participant, and frequency of interventions at the four required contacts. Intensity of the interventions for all contacts was also analyzed. By examining the data using both frequency and intensity, the research team was able to see variations in how interventions were used with participants.
Interventions for All Contacts
APNs averaged 4.6 participant contacts during the intervention for a total of approximately 579 intervention contacts in this analysis. There were 46 (42%) participants who had at least one extra contact. Out of the 35 combined EE and NIC interventions used, the four EE interventions were implemented in 52% of all APN contacts. Of the EE interventions, APNs used verbal encouragement with the largest number of participants, followed by mastery, vicarious experience, and reinterpretation of symptoms. The number of participants receiving the EE interventions for all contacts is displayed in Table 1.
Six NIC interventions were implemented with 75% or more of the participants for all contacts. Exercise promotion was used by the APNs with the largest number of participants. The number of participants receiving NIC interventions for all contacts is displayed in Table 2.
Interventions at Four Contact Points
The EE interventions were analyzed at each of the four required APN and participant contact time points: home visit and 2-week, 6-week, and 10-week telephone calls. The number of participants receiving EE interventions at the four required contacts is displayed in Figure 2. Verbal encouragement had the highest usage at each of the four contact times.
The six NIC interventions most frequently used over the four specified contact points were examined (see Figure 3). Usage of the interventions varied over the 12 weeks as the participants progressed through their recoveries.
Intensity of Efficacy Enhancement and Nursing Intervention Classification Interventions
A combination of eight EE and NIC interventions with a mean intensity of 1.42 and above (on a scale of 1–3) from all APN and participant contacts was examined (see Table 3). Telephone triage, an NIC intervention, was given with the greatest intensity but was used with only 4 (3.6%) participants. Counseling ranked next in intensity. Mastery and verbal encouragement had the highest intensity of the EE interventions. These were followed in intensity by four other NIC interventions: active listening, patient contracting, behavior modification, and socialization enhancement. The following two EE interventions were used with much less intensity: vicarious experience (M = 1.21, SD = 0. 41) and reinterpretation of symptoms (M = 1. 09, SD = 0.28).
Researchers describe the need for multidimensional interventions for rehabilitation and the successful management of chronic disease. Knowledge is necessary to meet common health needs. Decision making is based on having enough and appropriate information. Problem solving and changing behaviors require skills that can be enhanced through skills mastery (Lorig & Holman, 2003; Resnick, 2002). Resnick proposed that social cognitive theory provides a framework for efficacy enhancing interventions in men and women 65 years and older, but other factors including social support and individualized care influence motivation and behavior.
The findings of this study support the use of the multidimensional approach. The most frequently used interventions in this study of cardiac elders came from a combination of EE and NIC interventions, with the NIC interventions representing the physiological and behavioral domains. Both EE and NIC interventions were integral to providing a bio-psycho-behavioral and educational approach. Energy management and exercise promotion, from the NIC physiologic domain, addressed activity and learning in the recovery process. Active listening, emotional support, and presence—all NIC interventions—were important to knowing the patient and in building and maintaining the APN–participant relationship. Since the majority of participants lived alone, having someone to be there for them and respond to their fears and concerns, as well as their successes, was an important element of the self-efficacy enhancement. Verbal encouragement, the intervention with the highest use, not only further supported the relationship, but also was an important strategy for building efficacy. Since at least three of the four required contacts were by telephone, verbal encouragement and persuasion were important components of telephone coaching. Carroll et al. (2001) found encouragement and support, validation and feedback, and “providing a listening ear” to be important telephone coaching techniques used by APNs to enhance efficacy. Mastery, in combination with patient education and teaching about disease process, enabled patients to understand which skills and behaviors were necessary to their recoveries and helped them to set and achieve realistic short- and long-term goals, organize resources, and implement problem-solving strategies.
Two EE interventions, vicarious experience and reinterpretation of symptoms, were less frequently used than the APNs expected. Vicarious experience requires a positive role model who has similar qualities and issues. Opportunities may have been limited for unpartnered elders who lived alone to observe similar others, except for example, those who attended cardiac rehabilitation. Reinterpretation of symptoms requires the patient’s expression of a feeling, fear, or symptom and it is possible some participants may have had difficulty or reluctance in expressing clinical events or symptoms. The goal and the associated APN activities for reinterpretation of symptoms may not have been as clearly defined as the other three EE interventions. In some cases, the APN may have documented a general intervention, such as disease process teaching, while giving the participant recovery information or help in reframing symptoms, rather than the more specific intervention of reinterpretation of symptoms.
Mastery, the most powerful mechanism in enhancing efficacy beliefs (Bandera, 1986), was not documented as an intervention used by APNs with all patients. This may indicate the effect of the patient’s age or the telephone method of intervention. Intervention selection and documentation by the APN may have also been a factor. For example, an intervention such as mutual goal setting, which may have been documented from the general perspective of the NIC description, also contained activities such as setting and achieving goals, which were part of mastery.
Variations in Time and Intensity
The variation in use of interventions over time, as well as in their intensities, suggests patterns of recovery in this cohort. Energy management, which received the highest emphasis at the home visit, decreased over the 12 weeks as exercise promotion increased. From 6 to 10 weeks, the period during which most patients began to resume activities of “normal life,” mastery was at its highest use, suggesting that fatigue had lessened and exercise goals were being met. Participants were better able to achieve success with actual health behaviors and were ready to explore other options such as a cardiac rehabilitation program. Verbal encouragement was also emphasized at the home visit and continued across the 12 weeks, as were two other key elements of maintaining a strong connection: active listening and emotional support.
Although used less frequently overall, vicarious experience and reinterpretation of symptoms were used more at the home visit when patients experienced more physical symptoms as well as anxiety. The timing of the home visit provided an opportunity for the APN to assist with reducing or reframing symptoms, as well as opportunities to offer vicarious experience through case examples from her practice.
Many of the interventions that were frequently used were of low intensity, while some that were rarely used may have been the major focus of a contact, giving them a high intensity rating. Telephone triage, for example, which had the highest intensity, was used with only four participants. The cluster of high-intensity calls reflects high-priority needs that often involved managing symptoms, learning to problem-solve and learning to cope. Studies have suggested the need for efficacy interventions not only to begin early in recovery and to continue beyond the first three months, but to be of stronger intensity (Barnason et al., 2003; Berkhuysen et al., 1999). Of all the interventions in this study, three were high in both frequency and intensity throughout the 12 weeks: mastery, verbal encouragement, and active listening. This triad of interventions suggests that they were seen as highly important to the APN in maintaining a connection and enhancing the recovery process. Identification of the frequency, timing, and intensity (nurse time spent) of the interventions used during the first 12 weeks at home provides guidance for implementing an efficacy enhancing intervention with cardiac elders.
A limitation of this study is the lack of evaluation of the intervention by the participants. Participant information about which interventions were most helpful and their timing and intensity would contribute to further refinement of the intervention. Knowing that the participants actually received and understood the interventions as the APNs intended and were able to act on them helps to ensure treatment fidelity (Resnick et al., 2005). Another limitation is the lack of examination of differences in the use of the nursing interventions by gender, cardiac diagnosis, and ethnic or social background. Measurement of total nurse hours needed to provide the intervention was not included in this study. These data would contribute to further development of a program of effective, individualized nursing interventions.
Conclusions and Implications for Practice
This study demonstrates that a cluster of theoretically driven EE interventions, in combination with well-documented NIC interventions, can be successfully implemented with a vulnerable group of cardiac elders. Although health outcomes were not part of this study, participants demonstrated the ability to accept guidance as they progressed through the first 12 weeks of their recovery. Almost half of the participants needed more than the four required contacts, a finding that should be considered when this intervention is used with older patients. The NIC interventions, which helped meet the learning, self-management, and coping needs of the participants, assisted in promoting their readiness for EE. Enhanced readiness allows the nurse to focus on more specific interventions to increase self-efficacy. For example, the nurse can progress from general cardiac teaching to more specific exercise goals to focus on mastery attainment, or the nurse can move from general counseling to a more focused verbal encouragement or persuasion to educate participants on the importance of an activity.
The specific interventions used with this group of participants suggest areas for assessment of patient problems or nursing diagnoses. Identifying lack of knowledge, difficulty implementing the therapeutic regimen, need for guidance in setting and meeting goals, desire for enhanced health management, and feelings of loss of control or powerlessness may help to focus nursing interventions that have self-efficacy enhancement as the goal.
Nurses in a variety of rehabilitation settings can individualize EE interventions to assist in the recovery activities of the elder cardiac patient. Variations in the use of interventions suggest that EE and NIC interventions can be individualized accordingly to the recovery trajectory of individuals. Interventions early in rehabilitation should include verbal encouragement, teaching energy management, and providing observation of role models. Setting realistic and achievable short-term goals early in rehabilitation provides an opportunity for a patient to experience success and is a key to achieving mastery. For example, the nurse and patient can identify specific daily or weekly goals for progressive walking and self-care. Positive feedback and reinforcement of previous achievements can be provided by the nurse through verbal encouragement. For patients in a community setting, this study supports the use of telephone follow-up as a low-technology, low-cost method to monitor, encourage, and teach patients in their progress toward mastery. Goals for the patient in the community may focus more on maintaining exercise and activity and managing or learning positive health behaviors. For example, an achievable patient goal may be to attend a cardiac rehabilitation program or to practice relaxation techniques daily. The nurse, through regular follow-up telephone calls, can monitor progress and provide support through active listening, verbal encouragement, and education.
Regardless of the setting, nurses can integrate specific EE interventions along with other nursing interventions from the bio-psycho-behavioral domains with cardiac patients 65 years and older. Verbal encouragement, exercise promotion, energy management, mastery, active listening, disease process education, emotional support and presence may be key interventions for the rehabilitation nurse.
This work was funded by a grant (R01 NR05205) from the National Institutes of Health, National Institute of Nursing Research awarded to Dr. Sally H. Rankin.
About the Authors
Elizabeth Hiltunen, MS RN CS, was an advanced practice nurse at Massachusetts General Hospital, Boston, at the time this article was written. Address correspondence to Elizabeth Hiltunen, 4 James Road, Ipswich, MA 01938; e-mail email@example.com.
Patricia A. Winder, MS RN, was an advanced practice nurse at the University of California, San Francisco, at the time this article was written.
Michelle A. Rait, MA, was a project director at the University of California, San Francisco, at the time this article was written.
Elizabeth F. Buselli, PhD APRN, was a research associate at the University of California, San Francisco, at the time this article was written.
Diane L. Carroll, PhD RN, is a clinical nurse specialist in the Department of Nursing at Massachusetts General Hospital, Boston.
Sally H. Rankin, PhD RN-C FAAN, is a professor and chair of the Department of Family Health Care Nursing at the University of California, San Francisco.
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