Cardiovascular Nursing

Naturalistic Decision Making in Everyday Self-care Among Older Adults With Heart Failure Background Every day, older adults living with heart failure make decisions regarding their health that may ultimately affect their disease trajectory. Experts describe these decisions as instances of naturalistic decision making influenced by the surrounding social and physical environment and involving shifting goals, high stakes, and the involvement of others. Objective This study applied a naturalistic decision-making approach to better understand everyday decision making by older adults with heart failure. Methods We present a cross-sectional qualitative field research study using a naturalistic decision-making conceptual model and critical incident technique to study health-related decision making. The study recruited 24 older adults with heart failure and 14 of their accompanying support persons from an ambulatory cardiology center. Critical incident interviews were performed and qualitatively analyzed to understand in depth how individuals made everyday health-related decisions. Results White, male (66.7%), older adults' decision making accorded with a preliminary conceptual model of naturalistic decision making occurring in phases of monitoring, interpreting, and acting, both independently and in sequence, for various decisions. Analyses also uncovered that there are barriers and strategies affecting the performance of these phases, other actors can play important roles, and health decisions are made in the context of personal priorities, values, and emotions. Conclusions Study findings lead to an expanded conceptual model of naturalistic decision making by older adults with heart failure. In turn, the model bears implications for future research and the design of interventions grounded in the realities of everyday decision making. This work was supported by the Agency for Healthcare Research & Quality (R21 HS025232). Dr Holden reports consultant payments from federal research grants awarded to the University of Wisconsin, Clemson University, Oregon Health & Science University, and Kent State University. He receives an annual honorarium for editorial duties from Taylor & Francis publisher. Dr Mirro reports grants from Biotronik Inc, the Agency for Healthcare Research and Quality, Medtronic plc, and Janssen Scientific Affairs; consulting fees/honoraria from iRhythm Technologies Inc and Zoll Medical Corporation; and nonpublic equity/stock interest in Murj, Inc/Viscardia. Dr Mirro's relationships with academia include serving as a trustee of Indiana University. Dr Toscos reports grants from Biotronik Inc, Medtronic plc, Janssen Scientific Affairs, and iRhythm Technologies, Inc. All other authors have no conflicts to disclose. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research & Quality or Parkview Health. Correspondence Richard J. Holden, PhD, Regenstrief Institute, 1101 W 10th St #421, Indianapolis, IN 46202 (rjholden@iu.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

A Pilot Study to Evaluate a Computer-Based Intervention to Improve Self-care in Patients With Heart Failure Background Cognitive dysfunction contributes to poor learning and impaired self-care (SC) for patients with heart failure. Objectives The aims of this study were to (1) evaluate the feasibility and acceptability of a nurse-led, virtual home-based cognitive training and SC education intervention to support SC and (2) evaluate the relationship between improvements in SC and cognitive change and examine 30-day readmission rates. Methods In this 2-phase pilot study, we used a prospective, exploratory design. In phase 1, recruitment criteria and retention issues threatened feasibility and acceptance. Significant modifications were made and evaluated in phase 2. Results In phase 2, 12 participants were recruited (7 women and 5 men). Feasibility was supported. All participants and the study nurse positively evaluated acceptability of the intervention. Median SC scores improved over time. Thirty-day hospital readmission rates were 25%. Conclusion Phase 1 indicates the intervention as originally designed was not feasible or acceptable. Phase 2 supports the feasibility and acceptability of the modified intervention. Further testing is warranted. This study was supported by NIH/NINR P20 NR015331-02 (funded as part of the University of Michigan School of Nursing, P20 Center for Complexity and Self-management of Chronic Disease [PIs: Debra Barton, PhD, RN, FAAN; Ivo Dinov, PhD], and Donald and Karin Allen Faculty Fund, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan). The authors have no conflicts of interest to disclose. Correspondence Cynthia Arslanian-Engoren, PhD, RN, ACNS-BC, FAHA, FAAN, University of Michigan School of Nursing, 400 N Ingalls, Room 2176, Ann Arbor, MI 48109 (cmae@umich.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Translation and Psychometric Evaluation of the German Version of the Thirst Distress Scale for Patients With Heart Failure Background In patients with chronic heart failure, thirst can be perceived as an intensive and burdensome symptom, which may have a negative impact on patients' quality of life. To initiate thirst-relieving interventions, assessment of thirst and its related distress is essential. At the time of this study, no instrument was available to evaluate thirst distress in patients with heart failure in Germany. Objective The aims of this study were to translate the "Thirst Distress Scale for patients with Heart Failure" (TDS-HF) from English into German and to test validity and reliability of the scale. Methods The English version of the TDS-HF was translated into German. A linguistically and culturally sensitive forward-and-backward translation was performed. Psychometric evaluation included confirmatory factor analysis, reliability in terms of internal consistency, and concurrent validity. Results Eighty-four hospitalized patients (mean age, 72 ± 10 years; 29% female; mean left ventricular ejection fraction, 36% ± 12%; 62% New York Heart Association functional classes III–IV, 45% on fluid restriction) from an acute care hospital were involved in the study. The item-total correlation ranged from 0.58 to 0.78. Interitem correlations varied between 0.37 and 0.79. Internal consistency was high, with a Cronbach α of 0.89. There was a high correlation between the total score of the TDS-HF and the visual analog scale to assess thirst intensity (r = 0.72, P ≤ .001), and a low correlation with fluid restriction (r = 0.35, P = .002). Conclusions The evaluation of the German TDS-HF showed satisfactory psychometric properties in this sample. The instrument is usable for further research and additional psychometric testing. The authors have no funding or conflicts of interest to disclose. Correspondence Christiane Kugler, PhD, RN, FAAN, Faculty of Medicine, Institute of Nursing Science, Albert-Ludwigs-University Freiburg, Elsässer Str. 2-o, 79106 Freiburg, Germany (christiane.kugler@uniklinik-freiburg.de). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

The Influence of Preparedness, Mutuality, and Self-efficacy on Home Care Workers' Contribution to Self-care in Heart Failure: A Structural Equation Modeling Analysis Background Home care workers (HCWs) are increasingly caring for patients with heart failure (HF). Previous studies have shown that they contribute to HF patients' care, but how their preparedness and their relationship with patients (mutuality) influence caregiving is unknown, as well as the role of HCWs' self-efficacy. Objective Guided by the Situation-Specific Theory of Caregiver Contribution to HF Self-Care, we investigated the influence of HCWs' preparedness and mutuality on HCWs' contribution to HF self-care and the mediating effect of HCWs' self-efficacy in the process. Methods We conducted a cross-sectional survey of HCWs who cared for patients with HF. The survey included the Caregiver Preparedness Scale, Mutuality Scale, Caregiver Contribution to Self-Care of HF Index, and Caregiver Self-Efficacy in Contributing to Self-Care Scale. We performed structural equation modeling and a mediation analysis. Results A total of 317 HCWs employed by 22 unique home care agencies across New York, NY, completed the survey. They had a median age of 50 years, 94% were women, and 44% were non-Hispanic Black. Results demonstrated that mutuality had a direct influence on HCW contribution to self-care and preparedness influenced their contribution to self-care, but only through the mediation of self-efficacy. Conclusion Home care workers' preparedness, mutuality, and self-efficacy have important roles in influencing their contribution to HF self-care. As a workforce increasingly involved in the care of patients with HF, knowing the mechanisms underpinning HCWs' contribution to self-care may illuminate future interventions aimed at improving their contributions and HF patient outcomes. This research was made possible, in part, through a generous donation by Douglas Wigdor, Esq. Dr Sterling and this research are supported by the National Heart, Lung, and Blood Institute (K23HL150160). Dr Riegel is supported by the National Institute of Nursing Research of the National Institutes of Health (R01NR018196). REDCap at Weill Cornell Medicine is supported by Clinical and Translational Science Center grant UL1 TR002384. The authors have no conflicts of interest to disclose. Correspondence Madeline R. Sterling, MD, MPH, MS, Weill Cornell Medicine, 420 E 70th St, Box 331, New York, NY 10021 (mrs9012@med.cornell.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Health-Related Quality of Life in Patients With a Left Ventricular Assist Device (QOLVAD) Questionnaire: Initial Psychometrics of a New Instrument Background Patients with a left ventricular assist device are a unique and growing population who deserve their own valid, reliable instrument for health-related quality of life. Objective We developed and tested the Health-Related Quality of Life with a Left Ventricular Assist Device (QOLVAD) questionnaire. Methods In a prospective, descriptive study, patients from 7 sites completed the QOLVAD and comparator questionnaires. Construct validity was tested using confirmatory factor analysis. Convergent validity was tested using correlations of QOLVAD scores to well-established measures of subjective health status, depression, anxiety, and meaning/faith. Reliability and test-retest reliability were quantified. Results Patients (n = 213) were 58.7 ± 13.9 years old; 81.0% were male, 73.7% were White, and 48.0% had bridge to transplant. Questionnaires were completed at a median time of 44 weeks post ventricular assist device. The 5 QOLVAD domains had acceptable construct validity (root mean square error of approximation = 0.064, comparative and Tucker-Lewis fit indices > 0.90, weighted root mean square residual = 0.95). The total score and domain-specific scores were significantly correlated with the instruments to which they were compared. Internal consistency reliability was acceptable for all subscales (α = .79–.83) except the cognitive domain (α = .66). Unidimensional reliability for the total score was acceptable (α = .93), as was factor determinacy for multidimensional reliability (0.95). Total test-retest reliability was 0.875 (P < .001). Conclusion Our analysis provided initial support for validity and reliability of the QOLVAD for total score, physical, emotional, social, and meaning/spiritual domains. The QOLVAD has potential in research and clinical settings to guide decision making and referrals; further studies are needed. This study was supported by grants from the following sources: Abbott-Northwestern Hospital Foundation, Minneapolis Heart Institute Foundation, and Minnesota Nurses Association Foundation. The funding sources had no role in the collection, analysis, or interpretation of the data. Additional support for K.E.S. was received from Bethel University (sabbatical). P.E. received honoraria from or is a consultant for Abbott Laboratories and Medtronic (paid to the institution, not the individual). S.M.J. receives speaking honoraria from Abbot (modest) and consulting fees from Medtronic (minimal). S.H. is a consultant for Abbott Laboratories. E.Y.B. received grants from Impulse Dynamics, personal fees from American Regent, and grants from Medtronic Inc. B.H. received a grant (shared with K.E.S.) from Minnesota Nurses Association Foundation (completed). All were paid to Minneapolis Heart Institute Foundation to be managed (not paid to the individual). J.A.C. Received personal fees from Abbott and Medtronic and is a member of the scientific advisory committee for Medtronic and Procyrion—all outside the submitted work. K.E.S. and B.H. are coauthors of the QOLVAD questionnaire and hold it as intellectual property. BH does contract work with Lippincott/WK as a Nurse Educator Consultant. (JCVN is owned/published by Lippincott/Wolters Kluwer - which is the owner of a Lippincott Clinical Experiences product from which BH receives royalties). [The QOLVAD questionnaire has been granted without charge to others who request permission in advance for nonprofit use.] Correspondence Kristin E. Sandau, PhD, RN, FAHA, FAAN, Bethel University, 3900, Bethel Drive, St Paul, MN 55112 (k-sandau@bethel.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Health-Related Quality of Life Declines Over 3 Years for Congenital Heart Disease Survivors Background Because of medical advancements, many congenital heart disease (CHD) survivors are relatively symptom-free until adulthood, at which time complications may occur. Worsening health status likely drives a change in patient-reported outcomes, such as health-related quality of life (HRQoL), although change in HRQoL has not been investigated among adolescent and young adult CHD survivors. Objective The aims of the current mixed cross-sectional and longitudinal study were to (1) examine changes in HRQoL over 3 years and (2) identify any demographic (age, sex, estimated family income, and distance from medical center) and medical predictors (functional status and number of cardiac-related medications) of that change. Methods Baseline and 3-year follow-up data were obtained via an online survey of 172 CHD survivors (15–39 years old at baseline; 25% simple, 45% moderate, 30% complex) recruited from a pediatric hospital and an adult hospital. Medical predictors were abstracted from electronic medical records. Results After controlling for New York Heart Association functional class, mixed-effects models identified significant declines in all subscales of the Research and Development Corporation 36-Item Health Survey 1.0 across the 3-year timeframe. A lower estimated family income (≤$35 000) predicted more decline in physical functioning (b = 0.5, 95% confidence interval, 0.2–0.8; P = .001) and emotional functioning (b = 0.3, 95% confidence interval, 0.1–0.5; P = .017). No other significant demographic or medical predictors were identified. Conclusions Study findings highlight the importance of tracking patient-reported outcomes over time, suggesting that medical staff should discuss HRQoL with CHD survivors during late adolescence and early adulthood before decline. The authors have no conflicts of interest to disclose. This work was supported by the National Institutes of Health (grant number T32HL-098039) to J.L. Jackson, The Heart Center at Nationwide Children's Hospital, and the Clinical and Translational Science Award (grant number UL1TR001070) to The Ohio State University and Nationwide Children's Hospital. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. Correspondence Jamie L. Jackson, PhD, 700 Children's Drive, Columbus, OH 43205 (Jamie.jackson2@nationwidechildrens.org). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Psychometric Properties and Factorial Structure of Vietnamese Version of the Hypertension Self-Care Profile Behavior Scale Background The Hypertension Self-Care Profile Behavior (HTN-SCPB) scale is a self-report instrument with which a patient's self-care behavior can be assessed. However, its psychometric properties for adult patients with hypertension in Vietnam require clarification. Objective The aim of this study was to translate the HTN-SCPB scale into Vietnamese and to assess its psychometric properties. Methods The study included 220 adult patients with hypertension. To evaluate test-retest reliability, 133 participants were tested twice with a 3-week interval between tests. For construct validity, exploratory factor analysis was used to assess factor structure, and confirmatory factor analysis was used to evaluate the structural model fit of the scale. Results Reliability was confirmed by internal consistency (Cronbach α = 0.79) and test-retest reliability (intraclass correlation coefficient, 0.88). The Kaiser-Meyer-Olkin value was 0.75, and Bartlett's test of sphericity was significant (P < .001) and adequate for exploratory factor analysis. A 5-factor structure was obtained, and the factors were named as follows: "advanced self-management skills," "adverse health behaviors," "medication adherence," "diet-related knowledge regarding hypertension," and "information skills." Confirmatory factor analysis revealed that the model fit indices were acceptable (root-mean-square error of approximation, 0.07) or slightly less than the good fit values (comparative fit index, 0.85; incremental fit index, 0.85; goodness-of-fit index, 0.88; adjusted goodness-of-fit index, 0.84; and Tucker-Lewis index, 0.82). Conclusions The Vietnamese HTN-SCPB scale had satisfactory validity and reliability for assessing self-care behaviors in patients with hypertension in Vietnam. The authors have no funding or conflicts of interest to disclose. Correspondence Pei-Shan Tsai, PhD, RN, 250 Wuxing St, Taipei, 110 Taiwan, ROC (ptsai@tmu.edu.tw). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Home-Based Versus Outpatient-Based Cardiac Rehabilitation Post–Coronary Artery Bypass Graft Surgery: A Randomized Controlled Trial Background The prevalence of coronary heart disease continues to increase in the Kingdom of Saudi Arabia (KSA). Despite advances in cardiac surgery, there are no established outpatient cardiac rehabilitation programs in the KSA. Objective The aim of this study was to investigate the effectiveness of home-based cardiac rehabilitation compared with outpatient-based cardiac rehabilitation and usual care for patients who are post–coronary artery bypass graft surgery. Method This 3-arm, single-blind, randomized controlled trial was carried out at the King Faisal Specialist Hospital, Riyadh, KSA. A total of 82 patients post–coronary artery bypass graft surgery were randomized and 73 patients completed the study. Recruited patients were distributed to home-based cardiac rehabilitation (n = 24), outpatient-based cardiac rehabilitation (n = 25), or usual care (control group) (n = 24). Participants in the intervention groups completed an individualized exercise program for 2 hours, 3 times a week for 8 weeks. The control group followed usual care (no intervention). The incremental shuttle walk test (ISWT), metabolic equivalence task, Short Form-36, and Hospital Anxiety and Depression Scale (HADS) were measured at baseline, postintervention, and after a 4-week follow-up period. Results Postintervention, there was an increase in mean ISWT score from baseline in both the home-based cardiac rehabilitation and outpatient-based cardiac rehabilitation groups (66 [0.58] m and 71 [9.19] m, respectively). No difference was observed in the control group. At the 4-week follow-up, both intervention groups showed statistically significant improvements in all outcome measures (ISWT, metabolic equivalence tasks, HADS-A, HADS-D, and Short Form-36) compared with baseline (all P < .001). The home-based cardiac rehabilitation group showed statistically continuous improvement compared with the outpatient-based cardiac rehabilitation group. The control group did not show any significant changes across time in outcome measures. Conclusion Home-based cardiac rehabilitation is as effective as outpatient-based cardiac rehabilitation. Home-based cardiac rehabilitation appears to be more effective at maintaining improvements follow the end of the intervention. Clinical messages: An 8-week home-based cardiac rehabilitation program is as effective as an outpatient-based program for improving functional capacity, physiological and psychological well-being, and quality of life for patients with coronary heart disease after coronary artery bypass graft surgery. The authors have no funding or conflicts of interest to disclose. Correspondence Mohammed A. Takroni, PhD, Department of Physiotherapy, King Faisal Specialist Hospital & Research Centre, PO Box 3354, Riyadh, Kingdom of Saudi Arabia 11211 (mtakroni@kfshrc.edu.sa). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Persistent Heart Failure Symptoms at Hospital Discharge Predicts 30-Day Clinical Events Background The relationship between heart failure (HF) symptoms at hospital discharge and 30-day clinical events is unknown. Variability in HF symptom assessment may affect ability to predict readmission risk. Objective The aim of this study was to describe HF symptom profiles and burden at hospital discharge. A secondary aim was to examine the relationship between symptom burden at discharge and 30-day clinical events. Methods An exploratory descriptive design was used. Patients with HF (n = 186) were enrolled 24 to 48 hours pre hospital discharge. The HF Somatic Perception Scale quantified 18 HF physical signs and symptoms. Scores were divided into tertiles (0–10, 11–19, and 20 and higher). The Patient Health Questionnaire-9 quantified depressive symptoms. Self-assessed health, comorbid illnesses, and 30-day clinical events were documented. Chi-square and logistic regression were used to examine clinical events. Results The sample (n = 186) was predominantly White (87.6%), male (59.1%), elderly (mean [SD], 74.2 [12.5]), and symptomatic (92.5%) at discharge. Heart Failure Somatic Perception Scale scores ranged from 0 to 53, with a mean (SD) of 13.7 (10.1). Symptoms reported most frequently were fatigue (67%), nocturia (62%), need to rest (53%), and inability to do usual activities due to shortness of breath (52%). Thirty-day event rate was 28%, with significant differences between Heart Failure Somatic Perception Scale tertiles (9.4% vs 37.7% in the second and third tertiles, respectively; χ22(N = 186) = 16.73, P < .001). Heart Failure Somatic Perception Scale tertile 2 or 3 (odds ratio [OR], 5.7; P = .003; and OR, 4.3; P = .021), self-assessed health (OR, 2.6; P = .029), and being in a relationship predicted clinical events. Conclusions Heart failure symptom burden at discharge predicted 30-day clinical events. Comprehensive symptom assessment is important when determining readmission risk. The authors have no funding or conflicts of interest to disclose. Correspondence Laura E. Senecal, DNP, RN, AGACNP-BC, Saint Francis Hospital, 100 Port Washington Blvd, Ste 105, Roslyn, NY 11576 (laurasenecal.dnp@gmail.com). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Depressive Symptom Trajectories in Family Caregivers of Stroke Survivors During First Year of Caregiving Background The purpose of this study was to identify patterns of depressive symptom trajectory and examine the associations of the symptom trajectory with caregiving burden, family function, social support, and perceived health status of caregivers of stroke survivors during the first year of caregiving after discharge from rehabilitation center. Methods Caregivers of stroke survivors completed a survey of depressive symptoms, caregiving burden, family function, perceived availability of social support, and perceived health status at postdischarge and 1 year. Patterns of depressive symptom trajectory (ie, symptom-free, symptom relieved, symptom developed, and persistent symptom groups) were identified by grouping depressive symptoms based on 2 assessments using the Center for Epidemiologic Studies-Depression. Repeated-measures analysis of variance and multinomial logistic regression were used to examine the associations. Results Of the 102 caregivers, 57.8% were symptom-free, 20.6% experienced persistent depressive symptoms, 11.8% relieved depressive symptoms, and 9.8% developed depressive symptoms. There were significant changes in family function (Wilks λ = 0.914, P = .038) and perceived health status (Wilks λ = 0.914, P = .033) among the groups during the first year of caregiving. The persistent symptom group reported the highest level of burden and the lowest level of family function and perceived availability of social support at both assessment times. Compared with symptom-free caregivers, caregivers with persistent depressive symptoms were 7 times more likely to have fair/poor health rather than excellent/very good health at 1 year (odds ratio, 7.149; P = .012). Conclusion Caregivers with persistent depressive symptoms are the most vulnerable to negative psychosocial outcomes and poor perceived health status during the first year of caregiving from discharge for stroke survivors. This study was supported by NIH R01NR02416 (King, PI) and the Chung-Ang University research grants (2018). The authors have no conflicts of interest to disclose. Correspondence Suk Jeong Lee, PhD, RN, Red Cross College of Nursing, Chung-Ang University, Seoul 06974, South Korea (lsj1109@cau.ac.kr). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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