The health of an aging United States population is of increasing concern at the policy level,1-2 provider level,3 and within various professional groups.4-6 The increasing growth of persons over 65 years suggests that low-cost, low-technology interventions will be needed to improve their quality of life while at the same time keeping healthcare costs within acceptable ranges.
Developing and tailoring interventions to best meet the needs of specific or targeted populations is a growing area for nursing and other health-related research.7-11 Randomized clinical trials of nursing interventions in the current literature lack meaningful description of the actions undertaken to affect change in patient outcomes. Researchers are forced to forgo description of the nursing activities in order to provide readers with comprehensive results. Therefore, little is known about which nurse activities work best to effect positive health outcomes.
To address this limitation in the current nursing literature, this article describes the activities of the advanced practice nurse (APN) as a coach to enhance the recovery in unpartnered elders after a myocardial infarction. This role of the APN as a coach (Fig. 1, study group 2) consisted of a postdischarge telephone intervention designed to improve recovery through nursing activities that supported the strengthening of self-efficacy expectation or confidence in the unpartnered elder after a myocardial infarction. Stronger self-efficacy expectation toward recovery behaviors are required by the elder to progress toward independent self-care, an outcome of recovery from myocardial infarction. This article does not purport to report outcomes of the study, but rather it describes from thematic analysis of the study data collection forms and narrative examples of the activities of the APN in this study.
The APN coaching intervention was based on the theoretic perspective of social cognition theory.12 This theory refers to self-efficacy expectation as the belief one has in her capability to organize and execute a course of action required to manage a life event. Self-efficacy expectation is concerned not with what capabilities one has but with judgments of what one can do with one's capabilities.13 Assuming ability, self-efficacy expectation has been identified as the primary determinant of whether a behavior will be initiated, how much effort will be put into the behavior, and how long the effort will continue.12 For example, it appears that sedentary individuals post-myocardial infarction who have favorable mood changes with mild exercise find that these mood changes play an early role in building motivation to adhere to an exercise program, whereas later on, goal setting and performance feedback become critical to self-efficacy gains.
Self-efficacy expectation is the product of a complex process of self-persuasion that relies on the cognitive processing of diverse sources of information.14 The most effective way of creating a strong sense of self-efficacy expectation or confidence is through mastery. Mastery is the actual performance of a behavior that allows one to overcome the fear and negative emotional arousal that may be associated with that particular behavior.
Social modeling, or vicarious experience, is seeing others perform the threatening activity without adverse events. While modeling can be influential in its extent and direction of effect, it can be unpredictable based on the perceived credibility of the person providing the information.15 Individuals seek proficient models that possess the competencies to which they aspire. Observing individuals post-myocardial infarction exercising at a cardiac rehabilitation program is observing proficient models for those who have recently had a myocardial infarction.
Social persuasion is the third way of enhancing self-efficacy expectation. Individuals who are persuaded verbally that they possess the capability to master given activities are likely to mobilize greater effort. In those that harbor self-doubt, it is important to identify small incremental changes that are attainable because unrealistic boosts in self-efficacy expectation can be quickly disconfirmed by disappointing results in one's efforts.16,17
Individuals also rely on their physiological and emotional states in judgment of their capabilities. Those who believe they cannot manage potential threats experience high levels of anxiety arousal and the release of catacholamines.18,19 It is important to know that it is not the sheer intensity of the emotional and/or physical reactions but rather how the individual perceives and interprets the reaction that determines how positively or negatively these reactions influence self-efficacy expectation. For example, a patient with fatigue after a myocardial infarction may view this fatigue as part of the healing process and may experience pleasure in knowing that the body is healing, while others may view this fatigue as a cardiac symptom and, therefore, a troubling sensation.
BACKGROUND ON THE IMPACT OF THE APN
Brooten et al.20 describe the transitional care model to address the special needs of patients who are faced with shorter lengths of hospital stay. This model substitutes for a portion of hospital care by providing a comprehensive program of transitional home care. In this model, the APN prepares the patient for discharge along with the other members of the healthcare team by coordinating patient teaching, following-up with physicians, and making referrals to community agencies as needed.
When the patient is home, the APN provides the direct care needed and also daily access via the telephone, which is an integral part of this transitional care model. The model has been successfully implemented with a variety of populations, including preterm infants and their families, women with unplanned cesarean births, pregnant diabetic women, and elderly patients with medical and surgical diagnoses.7
Attempts at identifying the interventions used by the APN in the first randomized clinical trial using the transitional care model,21 Cohen and colleagues22 conducted two independent content analyses of the nursing records and classified each intervention according to the Taxonomy of Ambulatory Care Nursing.23 With home visits included for 18 months, the most common classification of interventions was direct care (98%). Healthcare maintenance (51%) and general assessment (48%) were the most frequent nursing actions.
Naylor et al.4,10 in a randomized clinical trial of the transitional care model, provided comprehensive discharge planning by an APN to a treatment group of elders with either a medical or a surgical diagnosis. The APN completed physical and environmental assessments, targeted interventions to improve patient and family self-management skills, and collaborated with the healthcare team members. Data analysis revealed that the control group had more frequent hospital admissions, with the treatment group having a total of 270 days of hospitalization and the control group having 760 days of hospitalization after enrollment in this study.
The researchers focused this holistic transitional care model20 on the patient, addressing not only disease specific issues but also primary health problems, comorbid conditions, and other health and social issues. This was believed to be the reason for the success of this model of care.
These studies, as well as others using the transitional care model,20 have provided the empiric evidence for the positive impact of the APN role on patient outcome; however, this model lacks a theoretical framework to direct the actions of the APN.
Gilliss and colleagues24 used social cognition theory as their theoretical framework and, therefore, were able to identify actual theory-driven activities of the APN in their study. This study comprised an eight-week clinical trial of nursing activities for postcardiac surgery patients. The APN used telephone calls to provide frequent individualized support and reinforcement of the in-hospital education from the study nurse and to provide information to enhance self-efficacy expectation. Both the intervention and the control groups showed improvement on quality of life with time, but the control group average was substantially (10%) below that of the intervention group. Significant main effects for time were found for all self-efficacy expectations that were measured for all subjects, suggesting that self-efficacy expectation increases over the recovery period.25 The only main effects for the intervention were seen in the self-efficacy for walking (p < 0.013). The main effect of the intervention on reported walking activities suggest that the intervention was effective in influencing walking activity as one marker of recovery.
These authors believed that their low-intensity psychoeducational nursing intervention increased patient self-efficacy expectation and promoted an increase in activity after cardiac surgery. Based on the work of these authors, Rankin and Carroll26 further developed an APN-coached intervention with a sample of vulnerable unpartnered elders post-myocardial infarction.
The participants in this analysis were three APNs who functioned as the APN coaches in the study, Mending Hearts Together: Improving Health Outcomes for Heart Attack Elders (R15 NR04255).26 These APNs were all clinical nurse specialists with a cardiovascular focus to their clinical practice.
These APNs provided nurse coaching to a randomly assigned group of post-myocardial infarction unpartnered elders (n = 44) inducted into a larger clinical trial. These post-myocardial infarction elders (mean age = 75 years) lived in the community and reported significant physical limitations in the early recovery period. Their limitations were related to profound fatigue, deconditioning related to hospitalization (median length of stay = 7 days), and to limited personal assistance and social support in the home (30% lived alone). All had been admitted to the hospital with a myocardial infarction.
Each subject had weekly contact for 12 weeks with the APN via the telephone. During the initial telephone call, the APN explained who she was (a nurse with advanced education and experience in cardiovascular nursing) and that she, with the subject's permission, would be calling each week to provide a source of support and guidance during the patient's recovery.
Also during this first telephone call, the APN ascertained the safety of the individual and initiated relationship development. Questions were asked regarding the patient's symptoms, any medication adherence issues, level of activity, adequacy of assistance with food preparation and cleaning, and plans to see the doctor.
Further telephone calls proceeded on a weekly basis to provide social persuasion and to outline strategies to manage the subjects' physiologic state and their responses to their illness. The APN worked on the development of a therapeutic relationship while gathering data about the existence of troubling symptoms taking cues from the subject as "to what may be important to them." Activity, which generally comes up naturally in conversation regarding recovery, was the area where the APN provided an active guidance role and social persuasion. Activity goals were discussed and mutually agreed upon based on the health status of the elder as well as the elder's adjustment to the cardiac illness. Each week the APN provided feedback and support to move the unpartnered elder along the recovery trajectory.
Data for this analysis consisted of free-text comments written by the APN on the Nursing Intervention Telephone Data Form. These forms created a log for the 44 subjects who were in the APN-coached intervention. During each weekly telephone contact with the subject, the APN completed a Nursing Intervention Telephone Data Form for a total of 12 forms for each of the 44 subjects.
The Nursing Intervention Telephone Data Form consisted of an assessment of current symptoms and treatments as well the identification of the current level of recovery behaviors. Based on the assessment data and discussion with the subjects, the APN used a variety of activities to enhance the level of self-efficacy expectation in each individual subject. These activities comprised the free-text comment section of the data collection form.
Data sources for analysis consisted of all available Nursing Intervention Telephone Data Forms in a log that represented a unique APN subject dyad. Data were analyzed and compiled as a log for each subject. The process of data reduction, data display, conclusion drawing, and verification were grounded in the recommendations of Miles and Huberman.27
Initially, each individual log was analyzed to capture its essential feature. Data from each log was subsequently reduced by name and pattern and coded to identify preliminary themes and categories. As the categories and themes of APN activities became saturated, salient and common activities were identified.
Validity or credibility of the findings was established through a variety of methods. An extensive audit trail articulated all design decisions and interpretation.28 Conclusions drawn throughout the analysis were verified by reviewing the logs and conferring with experts on the research team. All interpretations were examined for plausibility, coherence, and replication with other data sources as well as from narratives written by the nurse interventionists.
A synthesis of the data revealed four themes of activities used by the APN during the APN-coached intervention. Primary activities identified were patient education, validation/feedback, encouragement/support, and problem solving.
The APN, in addition to answering questions, provided patient education. Self-management techniques about diet, activity, medication adherence, symptom identification, and risk-factor modification were all part of the content of the telephone interventions. Standard information that was part of the discharge instructions were reviewed and reinforced. Attendance at cardiac rehabilitation programs was strongly encouraged. The APN notations included: "we discussed angina in great detail," and "I answered many questions and offered feedback on activity progression."
Expanding on the theme of "providing a listening ear," the APN provided more than just listening for the elder. The APN listened attentively to the elder but then validated and affirmed the patient's thinking, experiences, progress, and accomplishments. This provided the elder with positive feedback and reinforcement. The validation process provided the forum for the development of a trusting relationship between the APN, the elder, and the elder's family. The APN was able to validate fatigue as a normal part of the recovery process and to offer suggestions on how to arrange daily activities to reduce this sensation. The APN notations included: "validated that weakness and fatigue were common," "affirm progress," and "the elder needed someone to listen to him."
The APN provided significant support and encouragement. The elders perceived themselves to be quite vulnerable during the study period. The APN provided a level of professional social support. The unpartnered elder lacked an in-home partner with whom to discuss thoughts, feelings, and symptoms. Elders appeared reluctant to share concerns with their children because their children became more vigilant and were perceived as threats to the elders' independence. The APN frequently documented "talking with subject about self-care in general" and "reinforced discharge instructions," and "provided social support."
Problem-solving and trouble-shooting issues and concerns was the final category of nursing activities. The APN assisted the elders with decision making and facilitated collaboration of the elders with their family and other members of the healthcare team. Problem areas that were discussed and noted on the nurses' data form were: getting prescriptions filled, developing plans for assistance when their was a reduction in family support, managing angina, and suggesting alternative transportation.
The actual interventions of the APN were theory-driven and reflected practice that was grounded in the specialty of cardiovascular nursing. The following are narrative examples from the APNs identifying their activities during this study.
APN Coach 1: C.S. was home for two days after having a myocardial infarction when the APN telephoned to initiate contact as part of the study. "The visiting nurse was here yesterday," said C.S. "and she told me to keep taking nitroglycerin for this chest pain." The APN queried C.S. about her symptoms, which revealed that she was having frequent chest pain at rest, similar to the pain she had with her heart attack, and this pain had only returned since she had come home. The APN was concerned about the symptoms and spoke with the nurse who had inducted C.S. into the study to obtain more information about her symptomatology. Subsequently, the APN insisted that C.S. contact her cardiologist immediately. Her cardiologist admitted her to the hospital and transferred her the next day for cardiac catheterization and percutaneous coronary intervention. In this case, the APN, by early assessment and collaboration with the in-hospital study nurse, was able to initiate quick and appropriate referral for medical treatment and intervention. "This intervention," said her cardiologist, "aborted a myocardial infarction."
In this narrative, C.S. was highly anxious because she had just returned home from the hospital and was having angina. C.S. had not yet had enough experience to appropriately process these symptoms. She required the assistance of the APN to provide guidance in interpreting symptoms. C.S. lacked the necessary understanding of her physiologic state and the skill to assess and self-manage her symptoms.
When C.S. returned from the hospital, the APN used verbal persuasion, embedded in the APN expertise, to facilitate the development of the necessary behaviors to reduce anxiety and to allow for successful self-management.
APN Coach 2: N.S.'s heart attack was easy for him, compared to the pain of the loss of his wife. The APN spoke weekly with him. His voice was flat, but there was a sense of his wanting to hear from a healthcare professional. He was doing all the things that you would want him to do to contribute to his recovery. He was keeping appointments with his doctors, walking regularly, and increasing his daily activity. He attended an open house for cardiac rehabilitation, and he even enrolled.
He made plans to go to Florida, a place that he and his wife went every winter. He was going to carry on, because he felt that it was a place where he could get out more and do some of the things that he enjoyed, like playing golf. As a matter of fact, his motivation for cardiac rehabilitation was partly based on the idea that it would help him to return to golf. The APN supported all these decisions. In Florida, he was playing golf and having dinner with relatives. He hoped that these activities would alleviate the loneliness that he felt each evening.
He did not feel sorry for himself, but one could feel tremendous empathy for him. One got the sense that each plan, each action that he undertook was an effort, that the psychological push, "the oomph," was just not there. N.S. had family support, a devoted daughter, and many friends and neighbors. But we believed that the APN telephone calls complemented all that was available to him. N.S. stated that the calls from the APN meant a lot to him. The APN offered an ear, some sorting out of his signs and symptoms, validation of his lonely feelings, praise for his efforts to carry on, and verbal persuasion to go on, with the suggestion that time might heal.
APN Coach 3: S.S. was born and bred in New England on a small island off the coast of Rhode Island. She was an 84-year-old female who sustained an anterior wall myocardial infarction who, the APN determined on her first telephone call, was going to do just fine. S.S. lived alone with her 13-year-old dog and did not have any living family to help her but was surrounded by close neighbors. The APN and S.S. worked together to identify weekly goals so that by the end of the intervention S.S. was walking two miles back and forth to the post office in her town. Each goal that she attained influenced her positive mood and level of confidence to reach mastery. When she reached the point when she could do what she had been doing before her myocardial infarction, she stated that she felt "that I am now recovered and back to where I was before my heart attack, but better, because I look at my life differently now." She was so encouraged that she could continue her life as she did before her myocardial infarction.
During one telephone call late in the intervention, S.S. started crying and revealed how incredibly frightened she had been about being alone. But knowing that the APN was a telephone call away gave her the strength she needed to feel safe as she recovered. Each week we discussed her goals and she set new goals for the week ahead. The APN provided consistent reinforcement and built upon her previous week's success. There were times when she felt immensely frustrated because she would say "in my mind I have the energy to do it, but my body wouldn't cooperate." S.S. experienced a significant amount of fatigue and would get upset when she didn't meet the goal she set for herself. The APN would offer verbal persuasion and management strategies for both her physical and psychological state and help her understand that this was a normal part of recovery and gently guide her to be patient and to reset a goal for the next week.
After completion of the 12 weeks of APN coaching it was difficult to bring what we had nurtured to a close. Not only was the APN given an incredible opportunity to get to know S.S., but also she trusted the APN and looked forward to their weekly conversations. We agreed that the APN would call every few weeks for another month and that if she ever needed the APN she could call and the APN would be there.
Each year, a number of unpartnered elders post-myocardial infarction experience unnecessary distress, poor health outcomes, and many place themselves at significant risk due to their compromised cardiac status, functional limitations, and inability to enhance their self-efficacy expectation. Their risk and functional levels may be effected by a lack of resources, comorbid conditions, and/or minimal social support, all of which can be potentially enhanced by the APN.
While each subject-APN dyad resulted in a unique individualized experience, there were overall common nursing activities used by the APN. The themes identified from the APN logs and the narrative examples validated the specialized activities of the APN in this study. Analysis of APN activities in other studies using the model of transitional care20 found similar activities, such as teaching, advocating, and counseling, to improve patient outcomes.22
Enhancing the self-efficacy expectation of unpartnered elders post-myocardial infarction can improve functional status and reduce risk of poor outcomes. The changes in self-efficacy expectation is an essential precondition for the development of appropriate self-management during the recovery period.29,30 Emphasis on enhancing self-efficacy expectation for recovery behaviors was a significant part of the APN nursing activities. These activities included the use of social persuasion, the sharing of vicarious experiences from other myocardial infarction patients, and the identification of strategies to manage the alteration in the physiologic and psychologic states that can occur postmyocardial infarction. The APN coach activities derived from social cognition theory offered the unpartnered elder a range of activities that facilitated the development of self-management skills, the identification of attainable goals, and the support and validation for the subject that contributed to the care provided by the healthcare team.
IMPLICATIONS FOR PRACTICE
With this vulnerable group of unpartnered elders, there are a number of implications for nursing practice. These include earlier follow-up with the healthcare provider and more in-home monitoring. The lack of an in-home partner support suggests that the need for professional support was greater than a partnered cohort. Referral to cardiac rehabilitation programs should also be emphasized as these programs offer not only nursing and medical surveillance but also provide an important social support mechanism.
The APN-coached intervention is a cost-effective low-technological way to extend specialized nursing services to unpartnered elders post-myocardial infarction. Our experience with 44 subjects found that cardiovascular APN activities provided specialized input useful for the recovery trajectory. The amount of time invested in each case, including assessment, telephone intervention, calls to the healthcare team members, and documentation averaged 8 hours per subject. The activities of the APN appeared to meet the unique needs of this highly vulnerable group.
The authors thank Debbie Skoniecki, MS, RN-C, Judy McGonagle, MS, RN-C, and Mary Kingston, MS, RN-C, for their invaluable insight on this study as part of a student experience in research. The authors also thank Christine Callahan, PhD(C), RN, Project Director, for the study.
This study was funded by a grant for the Medical Foundation, Charles Farnsworth Trust and the National Institute for Nursing Research (N15 NR04255).
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