capstone final

Running head: ASSESSMENT OF RN CASE MANAGERS KNOWLEDGE OF 1

Assessment of RN Case Managers Knowledge of Current Evidence-Based Nutritional Guideline

Recommendations for Heart Failure Patients

Brittany Rose BSN, RN, CCM

Western Governors University

A Capstone Presented to the Nursing Faculty

of Western Governors University

in Partial Fulfillment of the Requirements for the Degree

Master of Science in Nursing, Leadership and Management

February, 2015

ASSESSMENT OF RN CASE MANAGERS KNOWLEDGE OF 2

Assessment of RN Case Managers Knowledge of Current Evidence-Based Nutritional Guideline


Abstract

The purpose of this study was to assess RN Case Managers’ knowledge of current evidence-

based nutritional guideline recommendations for heart failure patients to determine if there was

a knowledge deficit that leadership should consider addressing. The study included 33

participants all employed with the researcher at the host organization. The researcher created a

17-question assessment including questions evaluating demographic information, evaluation of

confidence level teaching the research topic, policy at the host organization, and clinical

guideline questions. Evaluation of the assessment results revealed a pronounced knowledge

deficit among nurse Case Managers at the host organization. Six of the 17 questions were

clinical guideline based and of the six, no single question had a majority of participants

answering correctly. After evaluation of participant answers to the 17-question assessment, the

researcher was able to ascertain an urgent need for additional education to provide updated

clinical guideline information on current evidence-based practice guidelines for heart failure

patients.


Acknowledgements

When I started the capstone journey I will admit I thought I would not need to enter any

“acknowledgements” but I now see why they put this in as part of the assignment. No family can

go unrecognized during a capstone and I would like to say thank you to my supportive husband,

no matter how much I believed I could not finish this and that it was the most difficult thing I

ever had to do, he simply told me “it will all work out”. The funny thing is, he was right, no

matter how much I cried and stressed myself to the max insisting it was the end of the world, he

would say, “this too shall pass”. Most of the time when he said these things to me I wanted to

throw something at him. As many times, as he had to talk me off the ledge, one would think I

would no longer be terrified of heights. I am so blessed to have someone that in worse case

would go tandem with me off that ledge, my husband encouraged me to move on for my degree

so he could see me “hooded” because he thinks I do so much as a nurse I deserve that part. I

think he just wants something that is big enough to catch all my tears when I pursue additional

education.


Table of Contents

Abstract………………………………………………………………………………………2

Acknowledgements…………………………………………………………………………..3

Table of Contents…………………………………………………………………………….4

List of Tables…………………………………………………………………………………9

List of Figures……………………………………………………………………………….10

Chapter 1: Introduction to the Problem …………………………………………………... 9

Introduction …………………………………………………………………….…....... 9

Presentation of Topic …………………………………………………………………. 10

Explanation of Topic………………………………………………. 11

Project Importance ……………………………………………………….……………. 12

Problem Outline …….…………………….………...…………………………………. 13

Background Information …….…………..…………………………………...………... 14

Causes………………………………………………………………………………….. 15

Research Question(s)……………………………………………………………………16

Best Practices Research………………………………………………………………....16

Chapter 2: Literature Review………………………………………………………………20

Research Question………………………………………………………………………20

Introduction ……………………………………………………………………….…… 21

Non-Pharmacological Prescriptions ………………………………………….………...22

Sodium………………………………………………………………………………23

Fluid……………………………………………………………………………........24

Barriers Effecting Implementation……………………….………………………......…25


Methodologies to deliver self-management education……………………………..........25

How patients process education... ……………………………………………………….25

Psychosocial barriers…………………………………………………………….............26

Behavioral and cognitive barriers……………………………………………………......26

Educating Nurses………………….………………………………………………………....27

Influencing factors determining the need for nurse education……………………...........27

Barriers to continuing education…………………………………………………………28

Time Constraints…………………………………………………………………………29

Leadership Support……………………………………………………………………....30

Conclusion ……………………………………………………………………………………....30

Chapter 3: Methodology………………………………………………………………………...32

Introduction …..………………...…………………………………………………………....32

Evaluation Tools and Methods………….…………………………………………………...32

Tools……………………………………………………………………………………..32

Methods………………………………………………………………………………….32

Reliability and Validity…………………………………………………………………..35

Integrity of Data and Data Use……………..………………………………………………..35

Research Design……………………….……………….…………………………………….35

Research Method…………………………..………………………………………………...36

Explanation of Research Method ………………………………………………………..36

Participants……………………………………………………………………………….......37

Permissions………………………………………………………………………………......37

Summary…………………………………………………………………………………......37


Chapter 4: Findings……………………………………………………………………………...39

Outline of Results …..………………………………….……………………………………39

Statement of Results…………………………………………………………………………39

Analysis...……………………………………………………………………………………40

Analysis of Demographic data……………………………………………………..………..40

Age, sex, role in organization……………………………………………………………40

Education, experience as a nurse and telephonic RN, and certification……………...…41

Clinical Based Questions…………………………………………………………….….43

Confidence of participants……………………………………………………………….43

Process at host organization………………………………………………………………….45

Host organization’s current clinical guidelines…………………………………………45

Clinical guidelines used at host organization…………………………………………....45

Clinical Guideline Questions………………………………………………………..……….46

Sodium intake for stage A and B heart failure…………………………………………...46

Sodium intake for Stage C and D heart failure……………………………………...…...47

Average sodium intake of general population……………………………………….…..47

Nurses prepared as educators for heart failure……………………………………….…47

High sodium foods…………………………………………………………………….…48

Sodium guideline recommendation for hypertension……………………………………49

Fluid intake for advanced heart failure patients……………………………………..….50

Research Question Answer ……………………………………...……………..…………....51

Summary……………………………………………………………………………………..52

Chapter 5: Discussion and Conclusions……………………………………………………….…53


Project Overview…………………………………………………………………………….53

Summary of Findings…………………….……………………………………………...53

How were results obtained…………………………………………………………….....53

Possible Solutions …………………………………………………...………………………54

Implications and Limitations…………………………………………………………...……54

Strengths…………………………………………………………………………..……..55

Weakness…………………………………………………………………………...……56

Problems…………………………………………………………………………………56

Factors…………………………………………………………………………………...56

Improvements………………………………………………………………………………..57

Further investigation……………………………………………………………………..58

What to do differently……………………………………………………………………59

Justification of differences……………………………………………………….59

Master’s Degree Experience.………………………………………………………………...59

Application in Work Environment…………………………………………………………...59

References ………….……………………………………….…………………………………...61

Appendices ………….……..……………………….……….…………………………………...69

Appendix A: Assessment of RN Case Managers’ Knowledge of Current Evidence-Based

Nutritional Guidelines………………………………………………………………………..69

Appendix B: Informed Consent………………...……………………………………………75


List of Tables

Table 1- Participant Demographic Data: Age…………………………………………………...41

Table 2- Participant Demographic Data: Sex…………………………………………………....41

Table 3- Participant Demographic Data: Role in the Host Organization………………………..41

Table 4- Level of Education in Nursing………………………………………………………....42

Table 5- Years of Experience Working in the Nursing Profession……………………...………43

Table 6- Years of Experience Working as a Telephonic Case Management Nurse…………….43

Table 7- Certified as Case Manager……………………………………………………………..43


List of Figures

Figure 1- Participant Confidence Level in Heart Failure Nutrition……………………………44

Figure 2- Sodium Intake for Stage A and B Heart Failure………………………………...…...45

Figure 3- Sodium Intake for Stage C or D Heart Failure………………………………………46

Figure 4- Average Sodium Intake by the General Population…………………………………47

Figure 5- High Sodium Foods…………………………………………………………………48

Figure 6- Sodium Guidelines for Hypertension Patients………………………………………49

Figure 7- Fluid Restriction for Heart Failure Patients…………………………………………50


Chapter 1: Introduction to the Problem

Introduction

Heart failure (HF) describes a condition where the heart cannot fill properly with blood

and/or pump effectively enough to circulate blood through the body properly (National Heart,

Lung, and Blood Institute [NHLBI], 2014 & Yancy et al., 2013). HF is a burden on the health

care system and the American Heart Association (AHA) projects that over the next 20 years the

real time medical expenses associated with heart failure will increase by approximately 200% if

cardiovascular disease is not adequately controlled (Heidenreich et al., 2011). Making an impact

on these staggering statistics is contingent upon whether patients can effectively manage their

condition without constant health care professional supervision. Patients are responsible for

implementing the necessary self-management skills to manage their HF and providing patients

with the necessary education for effective self-management is the responsibility of the health

care team, more specifically, the nurse.

The American College of Cardiology and the American Heart Association (ACCF/AHA)

2013 HF Guidelines indicate that patients must be educated on self-care for improved patient

outcomes; education on self-care involves educating about self-management skills. Self-

management skills include several non-pharmacologic interventions such as monitoring for

symptoms of fluid retention, weight fluctuations, restriction of dietary sodium and fluid, taking

prescription medications as instructed, and staying physically active (Boren, Wakefield,

Gunlock, & Wakefield, 2009; Riegel et al., 2009; Yancy et al., 2013). Management of fluid

retention symptoms, fluctuations in weight, and maintaining the ability to stay physically active

all seem to hinge on one very important self-management skill: adherence to nutritional

guidelines. The CDC (2013) lists three self-management skills that heart failure patients can


take to prolong their life and improve overall quality of life; one of the three is nutrition, more

specifically, management of dietary sodium (Centers for Disease Control and Prevention [CDC],

2013).

According to Alves, Souza, Brunetto, Peggy, and Biolo (2012), patients lacking the

important details about restrictions and limitations are likely to have poor management of their

heart failure. Poor self-management skills are associated with poor quality of life (QoL) for HF

patients however, several studies indicate that patients participating in nurse-led education

programs that focus on self-care exhibit improved QoL. Patients who have an increased

understanding of their heart failure are demonstrate an improved QoL and increased ability to

implement prescribed non-pharmacologic interventions (Albert, 2012; Boren et al., 2009; Riegel

et al., 2009; While & Kiek, 2009).

Presentation of topic. Increased utilization of evidence-based practice has brought

attention to the lack of research supporting non-pharmacological approaches to management of

heart failure. In addition to the lack of available research for previous and current guidelines

there is a growing recognition of knowledge deficit among nurses regarding evidence-based

approaches for management of HF (Albert, 2013; Johansson, Fogelberg-Dahm, & Wadensten,

2010; Washburn & Hornberger, 2008). The American College of Cardiology and the American

Heart Association (ACCF/AHA) revised the self-management nutritional recommendations for

heart failure (HF) in 2013 making the nutritional guideline recommendations increasingly vague.

The previous ACCF/AHA guidelines, while more specific, included minimal research supporting

the recommendations. The new recommendations offer general guidance for practitioners but

make the need for additional research overwhelmingly obvious.


Nurses are pivotal in providing the necessary education to HF patients for managing their

condition, placing emphasis on interventions associated with improved patient outcomes namely,

nutritional guidelines recommendations. Diet is the most commonly prescribed non-

pharmacological nutritional recommendation and sodium limitation is the most common dietary

recommendation, followed by fluid restriction (Linhares, Alti, Castro, & Rabelo, 2010).

Focusing on nutrition is an excellent place to start since it is associated with improved healthcare

outcomes for HF patients (Boren et al., 2009).

Case Managers (CM) are not always nurses but in this research project, the CMs

participating in the research project are all RNs CMs. A CM has a multifaceted role that

encompasses many aspects of the health care system requiring excellent communication and

collaboration skills. CMs are responsible for collaborating with multidisciplinary team members

and developing interventions to meet the complex needs of patients (Commission of Case

Management Certification, n.d.). Telephonic RN CMs at the host organization have the same

responsibilities as a CM, with the exception of performing the role solely through telephone calls

to patients, physicians, and ancillary providers (UnitedHealth Group [UHG], 2014).

Explanation of topic. Heart failure is a silent and progressive disease, setting it apart

from other chronic illnesses, creating a barrier to adherence of self-management behaviors that

are vital to the survival of HF patients (Albert, 2013). The disease’s progressive nature often

results in unexpected, rapid deterioration, subsequently the need to re-evaluate and change the

patient’s self-management plan is inevitable, and consequently these frequent changes are

associated with a decrease in the ability to make behavior change on a long-term basis

(Smeulders et al., 2010).


Patients lacking the important details about restrictions and limitations are likely to have

poor management of their heart failure (Alves, Correa Souza, Brunetto, Schweigert Perry, &

Biolo, 2012). Ironically while studies reveal patient non-adherence to prescribed non-

pharmacologic care is an issue, studies also reveal that the nurses providing inpatient care to

heart failure patients adhere to less than half of the non-pharmacologic prescribed care (Linhares,

Alti, Castro, & Rabelo, 2010).

Heart failure is undeniably the most common cause of hospitalizations and with a desire

for patients to effectively self-manage, their condition puts nurses in an important role of

educating about all aspects of heart failure with an emphasis on those interventions associated

with improved heart failure patient outcomes (Boren et al., 2009). Son, Lee, & Song (2011)

researched the effects of dietary restrictions particularly the sodium restriction diet (SRD) and

were able to show correlation that symptoms were greater when patients did not adhere to the

SRD thus making a need for proper education to patients to help them better understand self-

efficacy.

The ACCF/AHA establishes current nutritional guideline recommendations according to

the patient’s stage of HF. Currently the ACCF/AHA recommends a sodium restriction of

1500mg/day for patients with Stage A & B HF, whereas the recommendations for Stage C & D

is less than 3000mg/day and there is limited research supporting the recommendation (Yancy et

al., 2013).

Linton & Prasun (2012) state that it is a patient’s right to receive the most current, high

quality evidence-based care, compelling nurses to ensure that the education and information

provided is exactly that.


Project importance. Currently in nursing, there is a lack of consistency in what nurses

are teaching patients regarding self-management nutritional guidelines for HF, largely due to

nurses own lack of knowledge (Albert, 2013). Expecting nurses to educate patients about

behavior modifications responsible for improving management of HF is not realistic when the

nurse is lacking current information on the topic.

Nurses responsible for educating patients with HF are not always confident with the

amount of knowledge they possessed regarding HF self-management creating a need for

assessing what deficits exist (Albert, 2013; Washburn & Hornberger, 2008). The researcher’s

project includes an assessment tool designed to identify deficits among RN CMs responsible for

educating HF patients at the host organization. Identifying knowledge deficits among nurses is

necessary before creating and implementing effective and relevant interventions to educate the

RN CMs. It is essential for nursing leadership to understand the nurses’ level of knowledge

when attempting to create best practice guidelines and to create an environment that supports

integration of evidence-based practice for increased success (Albert, 2013; Linton & Prasun,

2013).

Providing nurses with an assessment tool evaluating level of knowledge regarding the

most current evidence-based practice nutritional guideline recommendations for HF prompts RN

CM reflection on what they currently consider and incorporate into their heart failure

discussions. After completion of the study, supplying RN CMs and leadership with both answers

and relevant resources allows for additional review of current evidence-based practice

information and hopefully can lead to additional educational assessments helping nurses identify

with knowledge deficits.

Explanation of the Problem


Problem outline. Currently the Heart Failure Society of America, European Society of

Cardiology, Canadian Cardiovascular Society, ACCF/AHA, Scottish Intercollegiate Guidelines

Network, and American Dietetic Association all vary on guideline recommendations for dietary

sodium and fluid restrictions (Gupta et al., 2012 & Lennie et al., 2011). Dietary sodium

restriction, fluid limitations, and weight management is acknowledged by many researchers as

being essential for improved outcomes in HF patients but without the recommendations being

communicated to the nurses responsible for educating patients these improved outcomes may not

be achieved (Albert, 2013; Gupta et al., 2012; Linhares, Alti, Castro, & Rabelo, 2010 & Yancy et

al., 2013).

According to Albert (2013), nurses responsible for educating HF patients were not always

confident with the amount of knowledge they possess regarding HF self-management, such as

weights, diet, and exercise and the amount of research available addressing the issues is scarce.

Identifying knowledge deficits among staff nurses at the host organization is necessary before

creating and implementing interventions addressing the identified deficits. It is essential for

nursing leadership to understand that their nurses level of knowledge when attempting to create

best practices (Albert, 2013).

RN Case Managers (RN CM) not having current knowledge of evidence-based nutritional

guideline recommendations for HF may have a negative impact on the confidence patients have

in the nurse responsible for providing them with the necessary education. The researcher is

assessing RN CMs knowledge of evidence-based nutritional guideline recommendations for HF

because it is likely that these RNs CMs are also lacking the necessary information for effective

patient education as previously mentioned (Albert, 2013). The time it can take to access

documents containing updated information or the confusion involved in interpreting the changes


may result in RN CMs redirecting their time to other aspects of their role i.e. heavy caseloads,

resulting in continued use of out dated information when educating patients. RN CMs must

continue education and learn how to interpret research if it is an area the RN CM is not

confident. The need for RN CMs is growing and continues to grow with health care reform and

the increase in age and complexity of patient needs making ongoing education increasingly

important for effective patient management (Tahan & Campagna, 2010; Tansey, 2010).

Background information. Inconsistencies with non-pharmacological interventions

prescribed for HF patients is prompting further review of literature in attempts to have a solid

foundation of what is safe information for HF patient education. For example, specific sodium

restrictions have been associated with non-pharmacological prescriptions in self-management of

HF patients; however, locating evidence supporting this common non-pharmacological

prescription has mixed findings (Linhares, Aliti, Castro, & Rabelo, 2010; Son, Lee, & Song,

2011). Linhares, Aliti, Castro and Rabelo (2010) identified that nurses were not carrying out the

prescriptions of the non-pharmacologic interventions, another reason for evaluating literature

associated with nurse knowledge and delivery of nutritional interventions.

Determining if a particularly methodology of self-management/self-care education

resulted in increased level of success is another area of intrigue to be researched. While and

Kiek (2009) discuss a study by Kutzleb and Reiner (2005), evaluating HF patients’ quality of life

(QoL) after nursing intervention involving patient education and found that self-efficacy is

dependent on the education by nurses. The outcome of the Kutzleb and Reiner (2005) study

demonstrated improvement in QoL, as well as evidence of increased self-management associated

with patients feeling empowered after receiving information and educational interventions


regarding their condition. Being able to improve QoL of HF patients would be life changing to

those patients struggling with self-management.

Factors influencing the need for additional education of nurses caring for HF patients was

identification of nurses not being as knowledgeable as expected when presenting evidence-based

information to patients and furthermore, the nurses not realizing their lack of knowledge

regarding guidelines, until surveyed in research studies is an important factor to consider (Albert,

2013; Higgins, Navaratnam, Murphy Walker, & Worcester, 2013). The researcher has concerns

that RN CMs at the host organization experience the same issues as identified above but there

have not been assessments distributed to nurses to begin to explore these likely deficient areas in

their practice. The researcher is hoping this research project will prompt further investigation

into gaps in knowledge of HF as well as other chronic health conditions.

Possible causes of the problem. A barrier to finding evidence-based dietary education

and interventions with a target audience of HF patients can be challenging because of the

obstacles encountered when measuring outcomes of diet intervention (Donner Alves et al.,

2012). Being in a controlled environment such as a hospital for a controlled kitchen environment

is not practical making accurate record keeping difficult for patients in their normal environment.

Health literacy is also a barrier to a HF patient’s ability to self-manage their condition (Chen et

al., 2013; Smeulders et al., 2010).

Albert (2013) states that heart failure is a silent and progressive disease, setting it apart


are vital to the survival of a HF patient. The disease’s progressive nature often results in

unexpected, rapid deterioration, subsequently the need to re-evaluate the patient’s self-


management plan is inevitable, and consequently these frequent changes are associated with a

decrease in the ability to make behavior change on a long-term basis (Smeulders et al., 2010).

The success of nurses being able to provide evidence-based non-pharmacologic

intervention for HF patients relies on the education of the nurses responsible for providing the

education (Albert, 2013). Albert (2013) acknowledges that while nurses may demonstrate basic

knowledge of HF patient education, additional research revealed that the nurses were not

comfortable providing education to patients about the topic, thus promoting the need for

intervention by leadership. The research demonstrates nurses’ reporting fewer barriers resulted

in a greater number of practice changes, and vice versa, and decreased number of barriers

resulting in less practice changes (Higgins et al., 2013). There was presence of a substantial

correlation between nurse self-efficacy and the perception of barriers. Accordingly, nurses

reporting greater self-efficacy reported a decreased number of perceived barriers four months

after the educational intervention. There was no marked correlation between self-efficacy and

the number of perceived barriers before or four months after the educational intervention, and

associating the amount of practice changes with nurse self-efficacy reports was not possible

(Higgins et al., 2013).


Chapter 2 Literature Review

Research Question(s)

What is the RN Case Managers’ current knowledge of evidence-based nutritional guideline

recommendations for heart failure patients?

Best Practices Research

Best Practices for effective non-pharmacological interventions. Best practice research

associated with nutritional guideline recommendations for heart failure patients involves review

of effective non-pharmacological interventions for HF patients; effective delivery techniques of

self-management education to HF patients; and best practices for nurses to overcome their own

identified knowledge deficits and level of self-efficacy regarding nutritional guideline

recommendations for HF.

Best practice for HF non-pharmacological interventions (NPI) is first evaluating the

patient’s perception of what self-management includes and their perception of what self-

management skills they currently possess. Utilizing education materials tailored to individual

educational needs for each patient is associated with improved quality of life and an increased

level of understanding about their condition(s) (Kato et al., 2012; While & Kiek, 2009). An

evidence-based practice intervention is providing tools or teaching how to create tools for

tracking dietary intake and dietary interventions helps a patient advocate for themselves and is a

best practice to incorporate into patient HF education (Leone, Walker, Curry, & Agee, 2012;

While & Kiek, 2009).

Best practices for effective self-management education. A best practice for providing

self-management education is creating and delivering culturally specific education. A pilot study

in Japan revealed that creating cultural specific, self-care education for the Japanese heart failure


population demonstrated favorable outcome with proven comprehension of heart failure

information. Those same patients indicated they would appreciate educational materials that

include information describing signs and symptoms signifying fluid overload with direction on

when they are justified in contacting their providers, prognosis, and indicate their level of

activity (Kato et al., 2012). The United States Census Bureau indicates the United States

population is currently comprised of 62.6% Caucasians; leaving 37.4% of the population

consisting of various cultural backgrounds and beliefs, developing culturally specific heart

failure literature is beneficial to the health care community (Kato et al., 2012; United States

Census Bureau [U.S. Census Bureau], 2014).

Using skills that patients can implement into their day-to-day lives is what makes an

impact on adherence to outcomes (Dickson & Riegel, 2009). Suggestions include involving

role-playing when discussing foods with hidden, high sodium content, having patients choose

which foods would be most appropriate for their diet and creating a diet from these activities.

Best practice for training of nurses. The effective design and the administration of a

HF training program for nursing designed by the Heart Research Centre was key to nurses

addressing and overcoming the barriers of self-efficacy, perceived barriers, and practice change

by developing an increase in nurses’ confidence that are responsible for educating HF patients

(Higgins et al., 2013). Albert (2013) discusses best practices designed to overcome the time and

comfort barriers for nurses by making the necessary educational information available via one

hour, computer based self-studies. Managing the barrier of time is achievable, requiring minimal

time for completion of the self-studies by focusing on the areas determined via survey, to be the

weakest and least taught areas of self-care education for HF patients by the nurses (Albert,

2013).


Suggestions to encourage EBP by Linton & Prasun (2013) include creating clubs for

nurses to meet on a regular basis to review literature and implement the research into the unit’s

guidelines; establish routine meetings on the unit to review evidence and discuss relevance to the

unit; and collaboration among staff and other departments to implement research among the

facility.

Literature Review Introduction

A search utilizing the Cumulative Index to Nursing and Allied Health Literature

(CINAHL), MEDLINE Plus Full Text, Health Business Elite, and the American Heart

Association databases for (2009-2014) peer reviewed scholarly articles, scientific and policy

statements eluted to a vast number of articles relevant to the researcher’s topic. Using the

combination of search terms; BOOLEAN/Phrase: heart failure, nutrition, and nursing; heart

failure and non-pharmacological; heart failure and sodium; heart failure and fluid successfully

provided articles narrowed down to the focus of the research topic addressing the knowledge RN

Case Managers possess regarding nutritional recommendations for heart failure and best

practices associated with the topic.

Identifying non-pharmacological prescriptions to include in self-management education

as well as identifying barriers possibly interfering with adherence to the prescriptions is

fundamental when trying to develop effective interventions to manage heart failure exacerbation.

This review of literature conveys the most relevant and up to date information for nurses

regarding evidence based, non-pharmacological nutritional recommendations for HF patients.

The researcher is synthesizing current research from 2008 and beyond, informing the reader of

what is known of the topic but taking note to discuss what is unknown regarding the topic as

well.


Non-Pharmacological Prescriptions

Effective management of any chronic condition relies on self-management skills,

effective management of HF involves adhering to non-pharmacologic self-care behaviors such as

dietary restrictions; exercising; weighing daily as a method to monitor for signs of fluid overload

(Riegel et al., 2009; While & Kiek, 2009). Inconsistencies with non-pharmacological

interventions prescribed for HF patients is prompting further research in attempts to have a solid

foundation of what is safe information for HF patient education. For example, specific sodium

restrictions have been associated with non-pharmacological prescriptions in self-management of

HF patients; however, locating evidence supporting this common non-pharmacological

prescription has mixed findings (Linhares, Aliti, Castro, & Rabelo, 2010; Son, Lee, & Song,

2011). Linhares et al. (2010) identified that nurses were not carrying out the prescriptions of the

non-pharmacologic interventions, another reason for evaluating literature associated with nurse

knowledge and delivery of nutritional interventions.Two of the most commonly prescribed non-

pharmacologic nutritional recommendations are sodium restriction and fluid restrictions

(Linhares et al., 2010).

Sodium. Sodium restrictions have been associated with non-pharmacological

prescriptions in self-management of HF for many years; however, locating evidence supporting

this common non-pharmacological prescription reveals mixed findings (Linhares et al., 2010;Son

et al., 2011; Washburn & Hornberger, 2008). Many articles, that include the key words diet and

heart failure, reference the topic of sodium intake and its effect on heart failure, the topic may be

those supportive of a low-sodium diet or those that argue against strict sodium restriction, but it

seems to be a common theme among these key words.


Nurses should consider varying factors that may interfere with patient adherence to a

sodium-restricted diet when making the self-management recommendations. Identifying a

patient’s knowledge of sodium-containing foods, other sources of sodium, and ability to

incorporate low-sodium diet into their lifestyle are factors that contribute to successful adherence

(Arcand et al., 2011). The consumption of pre-packaged foods and fast foods is repeatedly

mentioned in various studies as the reason for insidious sodium intake among HF patients (Alves

et al., 2012; Philipson, Ekman, Swedberg, & Schaufelberger, 2010; Son et al., 2011). Patients

being able to comprehend and correlate the effects of consuming excessive sodium and feeling

poorly are associated with greater adherence to the recommendations (Son et al., 2011; Welsh et

al., 2010).

The host organization utilizes the most current ACCF/AHA Guidelines as the standard

for all HF clinical recommendations within the organization (UnitedHealth Group [UHG], 2014).

The 2013 ACCF/AHA HF Guidelines recommend a 1500mg/day sodium restriction for patients

with both stage A & B HF; however, stage C & D recommendation are vague at <3 g/day

because of the minimal research available to indicate otherwise at this time (Yancy et al., 2013).

Sodium consumption in the general population is estimated by the ACCF/AHA as being more

than 4,000mg/day creating a seemingly large gap in what is recommended and what is actually

consumed (Yancy et al., 2013).

Fluid. Much like sodium, research involving fluid management and the effect on HF is

limited and outdated resulting in what recommendations are available among recognized

organizations throughout the world are inconsistent (Gupta et al., 2012). The 2013 ACCF/AHA

Guidelines support restriction of fluid to 1.5-2L/day for patients with advanced HF, also known

as Stage D, with the goal being to manage hyponatremia and reduce risk of HF exacerbations


(Yancy et al., 2013). A prospective study published by the European Heart Journal in 2010 is

one of the first studies of its nature; the findings indicate that fluid management, as well as other

non-pharmacologic interventions, are associated with having a direct adverse effect on HF

patient outcomes (Van der Wal, Van Veldhuisen, Veeger, Rutten, & Jaarsma, 2010).

Barriers Affecting Implementation

Identifying specific barriers that may be interfering with the ability of a HF patient to

effectively implement the self-management education is important in being able to increase

adherence. While studies are limited in, the area of non-pharmacological interventions and the

outcomes associated with adherence or lack thereof Van der Wal et al. (2010) conducted a study

that proved an important valuable point, which is that adverse outcomes area associated with

whether patients adhere to non-pharmacological recommendations.

Methodologies to deliver self-management education. Determining if a particularly

methodology for self-management/self-care patient education results in an increased level of

success is another area of intrigue to be researched. While and Kiek (2009) discuss a study by

Kutzleb and Reiner (2006), evaluating CHF patients’ quality of life (QoL) after nursing

intervention involving patient education, results support the concept of self-efficacy being

dependent on education by nurses. The outcome of the Kutzleb and Reiner (2005) study

demonstrated improvement in QoL, as well as evidence of increased self-management associated

with patients feeling empowered after receiving information and educational interventions

regarding their condition. Being able to improve QoL of CHF patients may be life changing to

those patients struggling with self-management thus, identifying the teaching methods that are

effective is a crucial barrier to overcome. A review of literature by Barnason, Zimmerman, &

Young (2011) reiterates what other researchers believe, and that is adherence to self-care


improves overall outcomes in HF patients, determining how patients convert what has been

taught by the nurse educators into information they apply in their daily lives is an area to be

researched.

How patients process education. Addressing how patients process the information may

contribute to non-adherence to self-management education. If patients cannot affectively

integrate what they have been educated into their lives then posing the question of whether the

time spent educating was worth it is something to consider. Dickson & Riegel (2009) discuss

concepts not mentioned in such a direct and focused way in other studies. These two authors

identify that the traditional methods used for patient education is not conducive to true

development of skills. Using the terms situational skills and tactical skills as the entire concept

of how patients are educated may solve the non-adherence issue that is so prominent in the heart

failure patient community (Dickson & Riegel, 2009).

Albert (2013) states that heart failure is a silent and progressive disease, setting it apart


are vital to the survival of a CHF patient. The disease’s progressive nature often results in

unexpected, rapid deterioration, subsequently the need to re-evaluate the patient’s self-

management plan is inevitable, and consequently these frequent changes are associated with a

decrease in the ability to make behavior change on a long-term basis (Smeulders et al., 2010).

Psychosocial barriers. Financial hardships interfere with accessing health care, such as

not being able to afford medications, copays for the necessary follow-ups with providers, and

even affording the gas to travel to and from educational classes (Boren et al., 2009). Involving

an assessment of psychosocial needs during the education process may be helpful to the nurse


when tailoring education for patients, being cognizant of the recommendations that involve

costly interventions, such paying for an educational course (Boren et al., 2009).

Review of many self-management programs for HF patients using Watson’s caring

model demonstrated a positive outcomes as a result, the lack of spiritual care application was

determined to be the least integrated into the self-management programs. Perhaps increasing the

incorporation of the spiritual care into the HF programs may increase the success and longevity

in HF patient life according to Lap Tong Leong, Sio Wa Lao, & Hao I Chio (2013).

Behavioral and cognitive barriers. Impairment of cognitive or behavioral function is

another barrier to implementation of interventions for self-management. Depression and anxiety

are behavioral conditions commonly diagnosed in HF patients (Riegel et al., 2009). The typical

signs and symptoms of depression such as fatigue, lack of interest in doing things, feeling

helpless or hopeless may be contributing factors to the poor adherence to self-care.

Remembering to communicate with the patient and any caregivers in a positive manner is

associated with better management of the condition, presenting the information in a manner

perceived as attainable the patient can develop confidence in their abilities to manage their

condition (Welstand, Carson, & Rutherford, 2009).

The ability for the elderly to recognize symptoms is noted in research as being

diminished related to the natural physiological changes that result in a decrease of cognitive

function that occurs with the elderly (Lam & Smeltzer, 2013). The cause of cognitive

impairments can vary from natural aging process, genetic anomalies, to actual anatomical

changes in certain areas of the brain that are directly an effect of HF. Making decisions is an

activity of the prefrontal cortex this area of the brain experiences anatomical changes providing a


valid explanation for the diminished ability to carry out tasks associated with self-management

(Riegel et al., 2009). .

Educating Nurses

Nurses are responsible for demonstrating a level of knowledge that is suitable for caring

for a complex condition, such as HF. A disparity between nursing practice and the utilization of

research into practice is a well-known problem in the nursing community (Johansson, Fogelberg-

Dahm, & Wadensten, 2010). Developing educational interventions for the nurses is a step that is

necessary so nurses are equipped with the knowledge that is directly associated with improved

outcomes.

Influencing factors determining the need for nurse education. Factors influencing the

need for additional education of nurses caring for HF patients include nurses admittedly not

being as knowledgeable as expected when presenting evidence-based information to patients and

the nurses not realizing their lack of knowledge regarding guidelines, until surveyed in research

studies (Albert, 2013; Higgins, Navaratnam, Murphy Walker, & Worcester, 2013). The research

from national and international sources indicates that nurses are not comfortable implementing

evidence-based practice indicating a need for nurse education (Linton & Prasun, 2013).

Medicare performance measures are an area of concern for leaders and educating nursing

staff about education of HF patients and self-management is an area to focus attention. Nurses

generally have the most contact with patients and providing proper education to help patients

better manage their condition resulting in a decrease number of readmission rates (Albert, 2012;

(Kato et al., 2012; McHugh & Ma, 2013).

Barriers to continuing nurse education. The successful implementation and adherence

to evidence-based, non-pharmacologic interventions for HF relies on the abilities of the nurse


responsible for providing the education. While nurses may demonstrate basic knowledge of HF

patient education, additional research reveals that the nurses were not comfortable providing

education to patients about the topic, thus promoting the need for intervention by leadership to

identify and resolve possible barriers (Albert, 2013). Identifying successful educational

techniques for teaching nurses the information necessary for being effective patient educators is

an area of ongoing research but there are studies available creating a foundation for reference by

nurse educators (Higgins et al., 2013; Linton & Prasun, 2013).

A study published by Higgins et al. (2013) investigates potential barriers to successful

education of nurses responsible for teaching HF patients; the study identified a relationship

between the nurses’ self-efficacy, perceived barriers, and their relation to practice change. The

increase in self-efficacy identified among nurse participants is encouraging and speaks to the

creation and delivery of the training program. The success of nurses being able to provide

evidence-based non-pharmacologic intervention for HF patients relies on the education of the

nurses responsible for providing the education (Albert, 2013).

Linhares et al. (2010) demonstrate that nurses perceive their knowledge of evidence-

based practice (EBP) as follows: 61% confident in the confident with being able to review their

own practice, yet 35% reported the ability to convert information into a research question. In the

area of attitudes, nurses report that research is not relevant to their professional practice at 59%

(Linhares et al., 2010). Research by Higgins et al. (2013) demonstrates nurses reporting fewer

barriers resulted in a greater number of practice changes and there was evidence of a strong

correlation between nurse self-efficacy and the perception of barriers. Accordingly, nurses

reporting greater self-efficacy reported a decreased number of perceived barriers four months

after the educational intervention. There was no marked correlation between self-efficacy and


the number of perceived barriers before or four months after the educational intervention, and

associating the amount of practice changes with nurse self-efficacy reports was not possible

(Higgins et al., 2013).

Time constraints. Nurses’ having more complex patients along with an increasing

patient load requirement creates a busy work day for nurses, not leaving much time for reviewing

or discussing literature. (Linton & Prasun, 2013). Nurses want to do the right thing and find

improved ways to carry out a task or procedure but with the lack of time it becomes an ongoing

issue ((Johansson et al., 2010; Linton & Prasun, 2013). Nurse Managers are responsible for

creating an environment supporting of implementation of evidence-based practice among staff.

A review of literature by Johansson et al. (2010) indicates that 73% of the nurses in the literature

reviewed justified time constraints as the greatest barrier for implementation of research.

Support from leadership. Leadership encouraging nurses to further education but no

incentive to do so may be a barrier to having nurses further their education. Furthering nurse

education to the point that they are able to have a true appreciation and understanding for

scientific methodology may bring more nurse to the field that are ready to integrate the new EBP

into practice. Nurses are more open to challenge the way things have been done when they grasp

the concept of EBP; thus, leadership must also be supportive and encouraging to the eagerness

the newly graduated nurse may bring back to the organization with the goals only to better it

(Johansson et al., 2010).

Conclusion

Literature clearly supports the use of EBP: whether it be nurses needing to learn EBP

about the non-pharmacological nutritional recommendations; the EBP associated with educating


the HF patients; or the EBP associated with educating the nurses responsible for educating.

Providing Nurses with the proper tools, whether it be didactic teachings to further their degree;

leadership allocating specific times for nurses to be able to stop working for one hour weekly to

review an assigned article, self-reflect on the article, design research questions associated with

the article. Scheduling small group discussions to review the information may create a sense of

comradery as well as being able to see each other as the contributors and a change-agents.

Without nurses understanding what EBP they are to be teaching patients a gap exists, this

assessment by the researcher identifies areas of missing knowledge. This creates the first steps

of correcting the problem by identifying the gaps in knowledge, investigating barriers, and then

resolving these barriers.

The next chapter, Chapter 3, is discussing methods best suited for the evaluation of the

data collected for this project. Identifying where the gaps in knowledge among RN CM

knowledge of the most current evidence-based practice nutritional guideline recommendations

for HF will help leadership determine what areas they can begin developing educational

information to present to nurses.


Chapter 3: Methodology

Introduction

Assessing RN CM knowledge of the evidence-based practice nutritional guideline

recommendations for heart failure patients and then analyzing the data may help leadership

develop education and training filling the identified gaps. Allowing the RN CMs to access

the research study results after researcher completes the study may be beneficial to the nurse

participants, allowing them to review areas where the department is lacking knowledge and

work as a team to make the necessary changes. The setting of the research project was at a

large health insurance organization in St .Louis, MO. The participants work with the researcher

as telephonic RN CMs and all work in a virtual environment from their homes and completion

of the questionnaires was to be on the nurses’ personal time.

Evaluation Tools and Methods

Tools. The researcher utilized a self-designed questionnaire comprised of seventeen

multiple-choice questions (see Appendix A for the Nurse Assessment Questionnaire) as an

instrument for the study. The questionnaire collected both nominal and ordinal data in a

multiple-choice format. Seven of the seventeen questions collect demographic information

pertinent to the study and the other nine are clinical based.

The researcher initiated the study by first distributing the assessment to potential

participants by sending an email via the intranet system at the host organization. The email

included the informed consent (See Appendix B) and a descriptive request for completing the

assessment.

Method. Evaluation methods include first, organizing the questions by category: six

demographic questions and nine clinical type questions. Assessing demographic data such as


participant age, sex, length of time working at the host organization, and length of time

participants have been a practicing nurse is included in the beginning of the assessment. While

the host organization requires all Case Managers to be Registered Nurses, some nurses may have

worked as licensed or vocational practical nurse (LPN/PN) before becoming RNs, so asking the

question how long a participant has been an RN may not capture the true number of years the RN

has been a practicing nurse. The intention is to have a sum of the years a nurse has worked in the

nursing profession, the question asks that participants combine the years practiced as an LPN/PN

and RN. The instrument gathers the participants’ highest level of nursing education and if the

nurses are Certified Case Managers (CCM) through a certifying organization.

The questionnaire then shifts to clinical questions assessing participant knowledge of

current evidence-based nutritional guidelines HF. The first of the clinical questions uses a Likert

scale asking participants to identify with the level of knowledge they feel they have regarding

evidence-based nutritional guidelines for HF patients. This question asks participants to choose

one of five levels of knowledge about HF nutritional care guidelines, labeled as 1-5 designed for

an easy correlation in the evaluation of results. Choosing “1” indicates the participant is not

familiar with evidence-based nutritional recommendations for CHF patients and does not feel

comfortable talking with a patient about these recommendations. A “2” is a nurse that

understands the basics of CHF nutritional care guidelines but requires the assistance of aids and

tools to assist them in teaching patients. A knowledge level of “3” indicates the participant is

confident in their already present knowledge about nutritional care guidelines and is comfortable

teaching other patients without additional tools or aids. Experts in the area of nutritional

guidelines for CHF patients would select “4”.


Much of the research in the researcher’s literature review focused on the effects of

sodium in heart failure patients and a majority of the guidelines do give some indication of

mg/day of sodium recommendation. Addressing knowledge of the 2013 ACCF/AHA

recommendations, as mg/day sodium intake, is an important component the assessment and is

demonstrated in tables and graphs for visual interpretation. The 2013 ACCF/AHA guidelines are

more specific in addressing the lack of true evidence supporting previous recommended sodium

allowances; the current recommendation by the ACCF/AHA for stage A and B heart failure

patients is adhering to 1500mg of sodium per day. Stage C and D HF have no precise

recommendations in the 2013 guidelines as addressed in the following question in the

questionnaire so demonstrating participant knowledge of this via a table allows for a visual

demonstration (Yancy et al., 2013).

The questionnaire asks participants to relate sodium intake into general concepts such as

daily sodium consumption and types of foods high in sodium. The average sodium intake for the

general population is more than 4,000mg in a day; some examples of less likely sources of

sodium include beets, chicken breast, and baking powder and the method of evaluation of

answers to this question involve presenting the data in a table format (Yancy et al., 2013).

Fluid intake and restriction is another aspect of HF guidelines lacking evidence making

exact recommendations difficult for the ACCF/AHA to endorse. ACCF/AHA does offer that

there is enough evidence supporting that patients living with stage D HF should consume no

more than 1.5 to 2L/day and the questionnaire challenges participant knowledge on this topic

demonstrating responses in a table format as well (Yancy et al., 2013).

ACCF/AHA Heart Failure Guidelines review past research citing JAMA (1996) and the

Journal of Internal Medicine (2001) that elevated blood pressure is a key factor in development


of both preserved and/or reduced ejection fraction heart failure (Levy, Larson, Vasan, Kannel, &

Ho, 1996; Wilhelmsen, Rosengren, Erikkson, & Lappas, 2001; Yancy et al., 2013). ACCF/AHA

states that controlling hypertension with current guidelines lowers the risk of developing heart

failure and cites numerous articles supporting this statement (Levy et al., 1996; Wilhelmsen et

al., 2001; Yancy et al., 2013). The AHA/ACC 2014 guidelines for lifestyle management to

reduce cardiovascular risk support patients consuming a sodium intake of no more than

2400mg/day demonstrating this knowledge in a table with the sodium and fluid assessment

results (Eckel et al., 2014).

Reliability and validity. Establishing validity and reliability of the researcher created

instrument goes beyond the scope of this research project.

Integrity of Data and Data Use

The informed consent explains how the integrity of the data of participants is kept

anonymous throughout all collection and utilization procedures. All participants of research

study will remain anonymous to the researcher via the Qualtrics® program anonymity feature.

Promise to participants that no use of names or any identifying personal information is collected

in this research study, further protecting the integrity of the participants and the data collected. It

is not possible for the researcher to discover participant identity at any point in time.

Research Design

This research study uses a simple descriptive, quantitative design approach evaluating

data obtained from answers participants provide via the multiple-choice assessment administered

by the researcher via Qualtrics®. There is no treatment offered by the researcher and the primary

purpose is to examine the relationship among RN CMs and the knowledge deficits that may or

may not exist with this specific population. All participants have received some form of nurse


onboarding education after hiring at the host organization, including a course specific to heart

failure; there have also been two heart failure presentations from the Medical Director in the last

eight years, contributing to available information for RN CMs at the host organization.

Research Methods

The researcher’s project is an objective study designed to demonstrate the level of

knowledge in the area of evidence-based nutritional guidelines for heart failure patients as

RN Case Managers. Through statistical analysis, the researcher evaluates demographic data

such as age, gender, years of experience and level of education. In addition to the

demographic data, the researcher assesses clinical knowledge via multiple-choice questions.

The researcher sent an email out with the request to complete the questionnaire, as well as

with the informed consent, allowing ten calendar days for completion.

Explanation of research method. The researcher uses statistical analysis to evaluate

quantitative data categorically and includes descriptive statistics, evaluating frequency

distribution; measure of central tendency including mean, median and mode; and percent of

distributions (Tappen, 2011). The researcher calculates frequency and percentage

distribution data for all questions in the assessment but is formatting the demographic data

and answers to the clinical questions into separate tables designed in Microsoft Excel®

. The

researcher determines the frequency and percentage distribution of the responses to the self-

evaluation question and representing responses in a pie chart. Calculating the central

tendency for the clinical questions may assist in finding data points worth future

investigation for research by the researcher or the host organization.


Participants

The participants in the study are RNs employed at a large health insurance organization

in St. Louis, MO, recruited via intranet email communication by the researcher. The researcher

will email 85 potential participants with an anticipated number of 30-40 respondents. The

researcher has a professional relationship with potential participants; all currently employed at

the same health insurance organization in St. Louis, MO.

Inclusion criteria required participants be RNs employed as a telephonic CM at the host

organization. Male and females are included in the email requesting participation, there are no

age limitations; no restrictions on level of experience; or type of nursing education when

determining who would be included as participants in the study. Excluding any of the RN CMs

employed at the host organization in a leadership role is a decision of the researcher, avoiding

any missed information or inaccurate information; leadership roles are identified as a team lead,

team lead supervisor, manager, and director of any kind.

Permissions

The host organization does not require IRB approval but the researcher was required to

complete the National Institute of Health online course titled: Protecting Human Research

Participants for both the host organization and WGU IRB approval.

Informed consent (see Appendix B) information is included in the email containing the

link to the survey, the informed consent indicates in writing that clicking the link to the survey

provides consent to participation. The researcher utilizes the Qualtrics® anonymity feature

keeping participant information private, protecting identity of participants.

Summary

Using responses from active RN CMs responsible for providing current evidence-based


nutritional guideline information to HF patients is an excellent way of incorporating first-

hand evidence-based data into practice. Leadership has the opportunity to utilize the data

collected and outcomes determined by the researcher and this researcher anticipates there

will be a response involving training specific to addressing the gaps in knowledge identified

by the assessment. Leadership at the host organization has indicated the plan to use the

results of the researcher’s study as guiding factors in development of future educational in-

services for RN CMs.


Chapter 4: Findings

Outline of Results

The researcher distributed an online assessment via Qualtrics® to 85 potential participants

at the host organization on January 24, 2015. The survey remained open until, February 2, 2015,

providing ten calendar days for completion. The results look into demographic data of the

participants creating information depicting a clearer picture of those completing the survey. The

results provide insight to participant awareness of the policy and procedure for locating current

evidence-based information and which information the host organization is using since

information does vary among organizations. The clinical questions look at knowledge of sodium

intake for all stages of HF as well as hypertension, identification of high sodium foods, sodium

intake among the general population, and fluid intake recommendations. The only question that

a majority of participants answered correctly was the question regarding which guidelines the

host organization recognizes as the standard for staff to reference; however, in a previous

question only two respondents of 33 knew where to locate the policy stating which guideline is

currently recognized. The host organization can choose to change which health organization

they choose to adhere to making it important to know where to find the information. A majority

of the nurses did indicate that research indicates nurses are not adequately prepared as HF

educators.

The results are presented first by reviewing varying aspects of demographic data,

evaluation of the nurses self-confidence in the research topic, host organization policy and

procedure for finding current guidelines, and clinical guideline knowledge questions.

Statement of Results

Less than half of the RN CMs participated in the assessment making the data less reliable


since only participant specific variables were included in the evaluation of the data. However,

the results of the assessment do create an opportunity for leadership to collaborate with the

education department to create educational in-services focusing on the identified deficits.

Despite only a small percentage of participants completing the assessment there were still a high

percentage of those participants that answered questions incorrectly or as unsure providing

leadership a place to start.

Analysis of Data

Analysis of demographic data. Researcher divides demographic data into specific areas

and discusses details including: participant ages, sex, role in the organization, level of education,

experience as a nurse and telephonic RN CM, and certification status.

Age, sex, role in organization. In this research project, participants were between the ages

of 20 and 70 years old, most were females, for further analysis of demographic data see Tables 1

and 2 for this information. Despite the clear information on the consent and clear in the

instructions indicating the exclusion of Team Leads and other leadership positions, two

participants indicate they are Team Leads and have completed the assessment either entirely or

partially, the remaining 31 responses were from clinical staff, not in a leadership role, see Table

3 for illustration. The anonymity feature interferes with resolving this discrepancy in data

collection but there seems to be no other discrepancies and data is still relevant. In the future,

researcher would consider a feature that may end the assessment if a participant selects any

option other than intended target.


Table 1. Participant Demographic Data: Age

Age n=

20-40 11

41-60 18

61-70 4

>70 0

Total 33 Note. Participants’ responses to the question, “What is your age range?” from the assessment found in Appendix A.

Table 2. Participant Demographic Data: Sex

Sex n=

Female 31

Male 2

Total 33

Note. Participants’ responses to the question, “Please indicate if you are male or female.” from the assessment found in Appendix A.

Table 3. Participant Demographic Data: Role in the Organization

Role in Organization n=

Clinical Staff, non-leadership role

30

Team Lead 2

Team Lead Supervisor 0

Clinical Manager 0

Total 32 Note. Participants’ responses to the question, “Please indicate your role within the host organization.” from the assessment found in Appendix A.

Education, experience as a nurse and telephonic RN, and certification.

Further analysis of demographics involves gathering additional participant demographic

information: such as level of education, experience as a nurse, years working as a telephonic

nurse, and whether certified as a Case Manager. Among 33 respondents, 22 (67%) have an

Associate’s Degree in Nursing, while seven (21%) of the nurses have their Bachelors of Science

in Nursing, leaving the less common education levels: Diploma of Nursing, 2 (6%); Masters of

Science in Nursing, 1 (3%); and Nurse Practitioner, 1 (3%).


The years of experience as a nurse varies among participants as shown in Table 5 from less

8 (24%) of nurses with less than ten years of experience to three (9%) of nurses having greater

than 40 years of experience in the profession of nursing.

Table 6 illustrates participant answers assessing the years spent as a telephonic RN Case

Manager with all categories ranking closely. Those being a telephonic Case Manager between 0-

3 years have a frequency and percentage distribution of 9 (27%); 3-6 years, 27% (9); 6-9 years

(8) 24% ; and more than 10 years is at 7 (21%).

The last of the demographic type questions is how many participants are Certified Case

Managers the frequency and percentage distribution; the researcher illustrates this data in Table

7. The requirement at the host organization is that within 2 years of hire the nurse is to be a

Certified as a Case Manager.

Table 4. Participant’s Level of Education in Nursing

Level of Education in Nursing n= % Associates Degree in Nursing 22 67%

Nursing Diploma 2 6%

Bachelors of Science in Nursing 7 21%

Masters of Science in Nursing 1 3%

Doctorate of Nursing Practice 0 0%

Nurse Practitioner of any specialty area

1 3%

Total 33 100%

Note. Participants’ responses to the question, “What is your highest level of education associated directly with the nursing profession?” from the assessment found in Appendix A


Table 5. Participants Years of Experience Working in the Nursing Profession

Years in Nursing Profession n= % 0-10 years 8 24%

11-20 years 11 33%

21-30 years 7 21%

31-40 years 4 12%

40 years 3 9%

Total 33 100%

Note. Participants’ responses to the question, “How long have you been licensed and practicing in the nursing profession?” from the assessment found in Appendix A.

Table 6. Participant Years of Experience Working as a Telephonic Case Management Nurse

Years of Experience as Telephonic Case Manager

n= %

0-3 years 9 27%

3-6 years 9 27%

6-9 years 8 24%

10 + years 7 21%

Total 33 100%

Note. Participants’ responses to the question, “How many total years have you worked as a telephonic Case Manager?” from the assessment found in Appendix A. Table 7. Certified as Case Manager

Certified Case Manager

n= %

Yes 19 58%

No 14 42%

Total 33 100%

Note. Participants’ responses to the question “Are you certified as a Case Manager by any certification organization recognized by the host institution?” from the assessment found in Appendix A.

Clinical Based Questions. This aspect of the assessment transitions to the clinical

knowledge of the participants. The data collected is not clinically specific initially but becomes

so more later on in the assessment.

Confidence of participants.

The first clinical based question is asking participants to evaluate their confidence

regarding current evidence-based nutritional guidelines for HF patients according to ACCF/AHA


guidelines, Figure 1 demonstrate participant answers to this question. The question asks

participants to choose one of four options the participant identifies with most in the area of HF

evidence-based nutrition. The first of the four choices is rating self as “inexperienced”, or

someone not comfortable talking with a HF patient about evidence-based nutritional guidelines

for HF patients. The second choice is “beginner”, an RN that understands the basics of

evidence-based nutritional guidelines for HF, but uses tools and aids during calls to assist with

discussion. The next option was “confident”, or feeling comfortable teaching patients about

dietary recommendations without the use of tools or aids during calls, this was the most

commonly chosen answer by participants with a 70% percentage distribution. The final option

was “expert”; two of 33 participants view themselves as someone that can educate patients, as

well as, other RNs about evidence-based nutritional guidelines recommendations regarding HF

with confidence.

Figure 1.

Participant Confidence Level in Heart Failure Nutrition

Figure 1- Percentage distribution associated with the question in the assessment located in Appendix A asking nurses to assess their level of confidence in knowledge of evidence-based nutritional guideline recommendations for heart failure.

Inexperienced, 0.00%

Beginner, 24.00%

Confident, 70.00%

Expert, 6.00%

Participant Responses

Inexperienced

Beginner

Confident

Expert


Process at host organization. The next two questions address the participant knowledge

of what practice is followed at the host organization identifying any need for reinforcement

education from leadership to ensure participants are aware of the recommended practice.

Host organization’s current clinical guidelines.

The ninth question asks participants where an employee would locate which guidelines are

currently followed at the organization and the answers varied with only two of 34 participants

knowing the correct answer. The correct answer is “Knowledge Library”; this is the intranet

website with the most current clinical guidelines listed for employees to access at any time on

any specific health condition including HF.

The most frequent answers from participants are “Any of the above”, 19 (56%); Milliman

Guidelines, 9 (26%); American Heart Association, 4 (12%). While the other options such as

American College of Cardiology, Heart Failure Society of America, and “none of the above” are

not selected 0 (0%). Leadership may want to address that there is such inconsistency with what

the answer is and what participants perceived it to be.

Clinical guidelines used at host organization.

The researcher asked what guideline recommendations the host organization recognizes as

the standard to reference for evidence-based self-management nutritional recommendations for

HF patients and 41% correctly answered this by selecting the American Heart

Association/American College of Cardiology. The frequency and percentage distribution for the

other choices are as follows American Dietetic Association, 1 (3%); Milliman Guidelines, 8

(24%); Heart Failure Society of America, 0 (0%); Any of the above, 10 (29%); None of the

above 1 (3%). The responses indicate a likely need for additional education by leadership so RN


CMs can seek out education consistently.

Clinical Guideline Questions. The following questions focus primarily on information

based on the current clinical guidelines established by the ACCF/AHA for heart failure and

hypertension.

Sodium intake for stage A and B heart failure. The first clinical knowledge question asks

participants to indicate what the mg/day of sodium the ACCF/AHA currently recommends for

patients with stage A and B heart failure. While the 2009 ACCF/AHA recommendations were

more consistent with the most common participant choice, ≤2000mg/day, the ACCF/AHA

updated the recommendations in 2013, indicating 1500mg/day as an appropriate amount of

sodium per day for patients with stage A and B HF (Gupta et al., 2012; Yancy et al., 2013).

Figure 2 further illustrates participant responses to this question, indicating a need for re-

education of participants.

Figure 2

Sodium Intake for Stage A and B Heart Failure

Answer

Response % 1500 mg/day

8 24% 2000 mg/day

16 48% 3000-4000 mg/day

0 0% No recommendations, ask physician for clarification

3 9%

Unsure

6 18%

Total 33 100%

Figure 2. This figure illustrates frequency and percentage distribution for the question, “What does the ACCF/AHA use as a guideline for mg of sodium per day for patients with stage A and B HF patients.”


Sodium intake for stage C and D heart failure. The second clinical knowledge question

addresses sodium intake for patients with stage C or D HF, there are no correct responses to this

question. The 2013 ACCF/AHA Guidelines for the Management of Heart Failure indicate there

is not enough research available to support a specific mg/day recommendation for patients with

stage C or D heart failure (Yancy et al., 2013). Figure 3, highlights an area of interest when

considering topics of discussion educators and/or leaders may want to discuss with participants,

with 19 participants indicating the answer to be 1500mg/day and ten being unsure.

Figure 3. Sodium Intake for Stage C or D Heart Failure

Answer

n= % 1500mg/day

19 58% 2000mg/day

2 6% 2500mg/day

0 0% Insufficient data to support a specific mg/day recommendation

2 6%

3000-4000mg/day

0 0% Unsure

10 30%

Total 33 100%

Figure 3. This figure illustrates frequency and percentage distribution for the question asking what stage C and D HF patients should limit sodium to per the ACCF/AHA guidelines.

Average sodium intake of general population. Participants are to identify with what they

thought or knew to be the average sodium intake of the general population and answers varied in

this question. The frequency of the data indicates seven of the 33 participants answering

correctly, that the general population consumes >4000 mg/day, to the most commonly chosen

answer with ten respondents of the 33, indicating 3,000-3,5000 mg of sodium per day is

consumed by the general population (Yancy et al., 2013). Table 4 indicates no one particular

answer to prevail over another while 27% of participants admit to being unsure.


Figure 4

Average Sodium Intake by the General Population

Answer

n= % 1500-2000mg

3 9% 2000-2500mg

2 6% 2500-3000mg

2 6% 3000-3500mg

10 30% >4000mg

7 21% Unsure

9 27%

Total 33 100% Figure 4. The responses are to the question asking participants to indicate how many milligrams of sodium per day the general population averages.

Nurses prepared as educators for heart failure. Asking participants to identify with what

they thought to be true of Nurses being adequately prepared to educate heart failure patients

agrees with research, Nurses are not adequately prepared to educate patients on heart failure.

This question was a simple true/false, trying to help nurses look at what they knew of themselves

perhaps or of other Nurses and their readiness to adequately educate patients, of 33 participants

24 (73%) believed that the research shows that nurses are not adequately prepared, whereas 9

(27%) felt that nurses were adequately prepared to educated about heart failure.

High sodium foods. The researcher asks participants to identify foods high sodium. The

researcher chose the foods listed as options because of the foods the AHA lists as “sneaky”

foods, these foods each are high sodium foods and may be important for RN CMs to be familiar

with these “sneaky” foods (American Heart Association [AHA], 2014). As illustrated in Figure

5, participants seem to lack familiarity with foods that are high in sodium and 82% opt for the

source, ham. None of the 33 admits to being unsure by selecting the choice, unsure, providing

valuable insight for leadership, if they choose to pursue findings from this research study.


Figure 5

High Sodium Foods

Answer

n= % A chicken breast

1 3% Beets

0 0% Baking Power

1 3% Ham

27 82% All of the above

4 12% None of the above

0 0% Unsure

0 0%

Total 33 100%

Figure 5. Frequency and percentage distribution of all answers to the question: “Which of these foods is considered high sodium?” from the assessment in Appendix A.

Sodium guideline recommendation for hypertension. The sodium intake guideline for

patients diagnosed with hypertension according to the ACCF/AHA is 2,400 mg per day and of

33 participants, four were able to answer this question correctly. Figure 6 demonstrates the

uncertainty participants have on this topic and illustrates the frequency and percentage

distribution of the participant answers. Participants at the host organization work with patients

diagnosed with hypertension that have not yet been diagnosed with HF; if nurses educate patients

on this recommendation perhaps, patients could have a decreased chance of developing HF if

they consume recommended levels of sodium.


Figure 6

Sodium Guidelines for Hypertension Patients

Answer

n= % Consume no more than 1500 mg/day

9 27%

Consume no more than 2000mg/day

15 45%


1 3%


4 12%

Consume no more than 3000-4000mg/day

0 0%

Unsure

4 12%

Total 33 100% Figure 6. Responses illustrate frequency and percentage distribution for the question asking what the sodium guideline, according to the ACCF/AHA, for patients with hypertension.

Fluid intake for advanced heart failure patients. The last question asks participants to

indicate an acceptable amount of liquid an advanced heart failure patient, also known as stage D,

can consume in a 24-hour period, according to the ACCF/AHA. Figure 7 illustrates, 9% of the

33 participants answered this question correctly, providing another education topic for

consideration by leadership. The ACCF/AHA has set a guideline only for patients with stage D

HF at the time of this project, the guideline indicates that 1.5-2 liters of fluid is acceptable and/or

reasonable, other stages are yet to receive an exact recommendation related to conflicting

research (Yancy et al., 2013).


Figure 7

Fluid Restriction for Heart Failure Patients

Answer

n= % 1.5-2 gallons/day

2 6% 1-1.5 liters/day

14 42% 1.5-2 liters/day

3 9% Tailored per doctor recommendation only

9 27%

2.5 liters/day

0 0% Unsure

5 15%

Total 33 100% Figure 7. Responses from participants expressed in frequency and percentage distribution for the question asking how much fluid is reasonable for an advanced HF patient to consume in a 24-hour period.

Research Question Answer

The research question asks RN Case Managers’ to take an assessment evaluating current

knowledge of evidence-based nutritional guideline recommendations for heart failure patients.

The current knowledge of evidence-based nutritional guideline recommendations for heart

failure patients is determined to be deficient among the RN CMs at the host organization after

analyzing the assessment answers provided by participants.

The questions based on clinical knowledge include asking participants to identify the most

current sodium intake recommendations according to the ACCF/AHA for patients with stage A

and B HF, stage C and D HF, as well hypertension. The number of correct responses versus

incorrect, as demonstrated in Figures 2, 3 and 6, implies an opportunity for re-education of

participants at the host organization. Additional clinical questions include asking participants to

identify the average daily sodium intake by general population; choose high sodium foods from

options listed, and assessing knowledge regarding fluid restriction and HF patients. The number

of correct answers to these questions support researcher’s statement that participant knowledge is

deficient and participants would likely benefit from additional re-education on current evidence-

based nutritional guideline recommendations for HF patients.


Asking participants to evaluate their own level of confidence in the area of current, evidence-

based nutritional guideline recommendations for HF patients using a Likert scale provide

conflicting results. A majority of participants select option 3, indicating confidence in the area

of current evidence-based nutritional guideline recommendations for HF patients, when in fact

participants answered the clinical questions incorrectly or admit to being unsure.

Summary

The outcome of this study concurs with literature reviewed by the researcher, nurses have a

significant role in providing HF education to patients, and ensuring nurses continues their

education on an on-going basis may help ensure that patients are getting the most current

evidence-based guidelines for their condition (Washburn & Hornberger, 2008). Leadership is

responsible for creating a supportive environment for continued learning of nurses responsible

for educating patients (Linton & Prasun, 2013). Leadership may consider using researcher’s

method of first assessing for deficits and then creating an educational in-service to focus on

addressing the identified deficits. Linton & Prasun (2013) indicate it is the right of a patient to

receive the most current evidence-based education; however, if nurses are not aware of the most

current evidence-based practice information it may be challenging for nurses to provide to

patients.


Chapter 5: Discussion and Conclusions

Project Overview

Incorporating evidence-based guidelines into practice brings to the forefront the apparent

lack of research available supporting non-pharmacological approaches to management of heart

failure. In addition to the identified lack of available research for development of guidelines

there is a growing recognition of knowledge deficits among nurses regarding evidence-based

approaches for management of HF (Albert, 2013; Johansson, Fogelberg-Dahm, & Wadensten,

2010; Washburn & Hornberger, 2008). So even if the research available and the organizations

that established guidelines had current, well-supported recommendations the concern that nurses

do not always have access or have time to review the information is a known challenge.

The researcher’s aim in this study is to assess RN Case Managers knowledge of current

evidence-based nutritional guideline recommendations for heart failure patients and if knowledge

deficits are identified work with leadership to ensure they have these results and can act on them,

as they desire. The director of the site was enthusiastic about the researcher’s project and looks

forward to reviewing the results and working with the education department to develop

intervention.

Findings Summary

The limited number of participants presented a concern to the researcher, creating a question

of whether there was an adequate sample to provide relevant results. The researcher sent email

to 85 potential participants and after 10 calendar days was able to have only 33 respondents.

There were six demographic questions, two questions assessing the host organization’s policy

and procedure questions, two questions asking for nurses’ opinions, and the remaining six were

clinical guideline based questions. Responses to the six clinical guideline questions reveal a


clear knowledge deficit with zero of the six questions having a majority of respondents

answering correctly.

How results were obtained. Results were obtained through administration of a survey that

was developed by the researcher via the online survey program, Qualtrics®.

Possible Solutions

Possible solutions for resolving identified knowledge deficit includes prompt educational in-

services providing nurses with the correct information to the stated questions and any additional

information that is deemed necessary by leadership. Developing educational handouts and

sending via email for RN CMs to reference while becoming familiar with the new current

information. Education department could develop weekly bulletins to send to nurses and

leadership incorporate an allotted, mandatory amount of time into the weekly schedule for nurses

to review these bulletins and any other information.

Another possible solution would be to assign a nurse each month to present a topic on a

specific, current evidence-based guideline to present to staff in team meetings, creating handouts

to distribute to the nurses for future reference. Keeping learning sessions brief allowing nurses’

time to absorb the education before presenting new information.

Implications and Limitations of Project

When reviewing the project as a whole the researcher can identify specific strengths and

weaknesses of the project as well as problems detected while conducting the study.

Acknowledging factors that may have skewed researcher’s findings is important so that in any

future studies these factors can be monitored and taken into consideration when creating the

study.


Strengths. Strengths of this project involve the researcher’s familiarity with what areas

nurses are and are not educated on because of working with the participants. The researcher is

also familiar with patient needs as well as company goals since the researcher and participants

work with the same patient population. The changes to the ACCF/AHA guidelines for

management of HF in 2014 created an area of concern for researcher to investigate since many

fellow colleagues completed nursing school many years ago, and Missouri is not a state that has

required continued education courses for maintaining licensure.

Despite the small percentage of participants, there is still strength in the results of the

study because of the low percentage of those that did participate, who could answer questions

correctly, identifying an obvious knowledge deficit regarding evidence-based nutritional

guideline recommendations for HF patients. Among 85 potential participants, there were 33

participants and often it was incorrect answers provided or unsure answers, this is still a

percentage of RN CMs that would benefit from receiving educational in-services, which is a

strength of the study. The design of the questions allowed researcher to capture data that may be

significant enough for leadership to create an educational intervention.

Weaknesses. Weaknesses of the research project include poor participation rate, perhaps

if the researcher were clearer on the directions and/or consent, that the organization and

leadership had given clearance and supported completion of the survey, participation may have

been greater. Researcher made this revelation after casually investigating the poor response rate

and learned that potential participants chose not to complete because of a fear of making the

company looking bad and a concern of job security if nurses answered incorrectly. Researcher

had not thought of this making this an area to be considered in future studies.


The inability to assess leaderships’ knowledge of the assessment questions (see Appendix

A) I think creates an area of weakness to follow up on. Ideally those in leadership roles would

want to assess their own level of knowledge but the willingness of them to volunteer to take the

assessment and not use resources to look things up would need to be an area of focus. The

leadership in this particular organization are not required to complete clinical based education

thus when an RN CM has a question it is a concern that the information the leader(s) are

providing are subject to the same issues as discussed throughout the research study that those in

clinical roles encounter.

Problems. One problem the researcher detected was not creating a time limit for the

assessment to be completed. This was not something the researcher considered until reviewing

the completed surveys and the time for completion. Upon review of survey completion, 30

participants were able to complete the survey within four to five minutes at the most; however,

three participants took a significantly longer amount of time to complete. This extended time to

complete the survey creates concern of whether the participants did perform some type of search

for answers, instead of following the directions and not performing internet searches or asking

colleagues, and using the “unsure” option if they did not know the answer.

Factors. It seems to be a general consensus among fellow colleagues that despite any

type of survey being anonymous there is a concern that in some way the company would find out

who answered what and then they could be held accountable and punished for this. This is

nothing within the researcher’s control, as the consent was clear that anonymity is absolute and

that it would be impossible for researcher or the host organization for that matter, to identify

which participants answered incorrectly.


Another factor that relates to problems with the researcher’s project is leadership insisting

that completion of the survey occurs on the employee’s own time. The researcher respected the

host organizations request, as it is understandable to not want to utilize company time for an

employee’s schooling; however, this project was designed to assist the host organization in the

area of nurse education and the researcher feels a valuable opportunity was lost. Had the

researcher known the poor response rate, an increased effort of the researcher to work with

leadership to make completion of the survey welcomed and seen as an opportunity among staff

by leadership would have been a focus.

Improvements

Improvements to be made with the researcher’s study is to try to have leadership more

involved with understanding what the MSN student is trying to achieve. The challenge that

researcher encounters is that many in leadership roles at the organization do not have beyond a

two year Associates Degree and are not ready and willing to allow a student to come them and

volunteer to assess the team and develop interventions to improve nurse knowledge and health

outcomes. Replication of research studies is common and as Burns & Grove (2007) discuss

replication is necessary in nursing, as well as, ongoing research to develop the strong evidence-

based practice desired in nursing. Making improvements to previous studies is an important step

in the research process and in this research study, the researcher is able to identify some areas of

further investigation and future changes that may increase participation.

A specific change the researcher would make in the assessment would be the

organization of some of the assessment questions. A specific change to the questionnaire would

be to ask participants to evaluate their level of confidence with their ability to provide current

evidence-based guideline recommendations to heart failure patients, at the beginning of the


clinical question portion of the assessment; and again as the last question. Enabling the feature

where participants cannot go back to change an answer would create a need for the question to

be asked again at the end of the assessment. The researcher would like to see if participants

identify themselves differently after seeing the type of information that clinical guidelines

address

Further investigation. An area that may benefit from additional investigation is

identifying if the level of nursing education and identifying if there is any association or

correlation with incorrect responses and level of education. Another area to consider further

investigation in is determining what interferes with the participants in seeking out the education

on their own to keeping them up to date on evidence-based practice guidelines and not relying on

the employer to provide the necessary education.

It behooves the host organization to begin evaluating RN CM knowledge in other disease

specific conditions regarding evidence-based nutritional guidelines such as diabetes,

cardiovascular disease, and cerebral vascular accidents. In addition to heart failure, diabetes,

stroke, and hypertension guidelines were also recently updated in the last one to two years and

ensuring proper patient education is being delivered is the responsibility of leadership and the

nurses.

While the researcher did intend to exclude those in leadership roles from this study it is

not being implied that it is not just as important for those in leadership to be assessed as it is

often they are referenced to making it imperative they are properly educated. The importance of

timing their assessment would be important because of a possible desire to search for answers to

avoid identifying a knowledge deficit.


What to do differently. If researcher were to repeat this study in the future it would be

made more clear in the directions that only non-leadership were to participate in the survey. In

addition to this the researcher would include the function in the survey program ending the

survey if a particular answer is selected. The researcher does not feel the results were skewed

too much by the two leaders that participated it still was not to be a part of this study thus making

the data still valid for reporting purposes to leadership.

Something else to do differently by the researcher in a future study is the amount of

involvement from the site director and team managers encouraging participation. The current

study did mention that the site director was aware of the study and approved completion of the

study on the nurses’ own time.

Justification of differences. Setting up the survey in a way that is certain to exclude

leadership would be done so that the answers are strictly from those responsible for educating

patients. As previously discussed, it still is important to evaluate knowledge of leaders on the

same topics but doing so in a separate study would be more appropriate.

Casual discussion with RN CMs after completion of the study revealed reasons that

nurses did not participate, many of these concerns may have been alleviated had they felt

leadership was supportive of this research project and encouraged participation. Asking

managers to allow researcher to speak at a weekly team meeting a week prior to distribution of

survey asking for participation may have reassured potential participants that management was in

support of the study. Having the site director possibly email potential participants or mentioning

it in an email would help confirm leaderships’ support of the researcher’s study.


Master’s Degree Experience

The experiences have gained these last 18-months have been something I could never

have predicted and have difficulty putting into words. Something I experienced in a Facebook

group for WGU students working on their MSN in Leadership and Management opened my eyes

to how I have been morphing over the last 18-months. I had come across one student’s response

after she completed her MSN, I was one term into my experience, but she made the statement

that she does not feel any “smarter” or feel like she gained anything from the Master’s

experience. Even though I was only one term in, when I read this statement from her I was

surprised and intrigued. My thought is that perhaps she had been someone who had already

achieved these milestones throughout her career and therefore this was simple for her and for

that, I think she is amazing and probably a very successful nurse. However, for me I cherish this

entire graduate experience and now that it is ending, I find myself feeling the opposite of that

nurse’s statement. I feel as I have almost completed the full circle in nursing and I “get it” more

than I ever knew to be possible. I am proud of my accomplishments and I am glad my teenage

daughters have seen me persevere through the tough times but still get to my goal. I think it has

set a good example and they will remember the long days I spent at the computer not being able

to participate in the festivities because of an assignment but hopefully see the end results of my

being a leader of some kind someday soon.

Work Environment. In terms of my work I have been able to share my learning

experiences and ways of doing things with both my coworkers and leadership. I am known

within the team as the nurse working on her Master’s, as many nurses do not have an advanced

degree nor do they indicate a desire to further their education. I hope to use my degree in a

way that will be most helpful to the nursing segment within my organization. Using leadership


and management techniques that are research based rather than following others in their

footsteps who utilize methods that have no research supporting them and thus they do not have

successful teams. Working in a corporate setting as a nurse can be challenging and having an

advanced degree will open up doors for me that otherwise I would struggle to open. I feel like

with an advanced degree I will be able to back up my statements that I love learning and love

doing things to help improve nursing and can demonstrate my dedication by proudly offering

my capstone as evidence of my dedication to the betterment of nursing. Many leaders within

my organization that manage nurses do not have a degree beyond an associates, with my

Master’s I hope to gain a leadership role and I hope to set a precedence that such a degree is

needed to effectively manage a team of nurses and achieve company goals.


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Appendix A

Assessment of RN Case Managers’ Knowledge of Current Evidence-Based Nutritional Guideline


Q1 What is your age range?

20-40

41-60

61-70

>70

Q2 Are you certified as a Case Manager by any certification organization recognized by the

host institution (Optum)?

Yes

No

Q3 How long have you been licensed and practicing in the nursing profession?

0-10 years

11-20 years

21-30 years

31-40 years

40 years


Q4 Please indicate if you are male or female.

Female

Male

Q5 What is your highest level of education associated directly with the nursing profession?

Associates Degree in Nursing

Nursing Diploma

Bachelors of Science in Nursing

Masters of Science in Nursing

Doctorate of Nursing Practice

Nurse Practitioner of any specialty area

Q6 How many total years have you worked as telephonic Case Manager?

0-3 years

3-6 years

6-9 years

10 + years

Q7 Select your role within the host organization:

Clinical Staff, non-leadership role

Team Lead

Team Lead Supervisor

Clinical Manager


Q8 Rate your level of confidence regarding current evidence-based nutritional guidelines for

heart failure patients according to American College of Cardiology/American Heart

Association (ACCF/AHA). Please use the definition associated with the assigned number

when selecting answer.

1= Inexperienced, not comfortable talking with a chronic heart failure patient about

nutritional guidelines

2= Beginner, understand the basics, use tools and aids during calls to assist with discussion

3= Confident, comfortable teaching patients about dietary recommendations without the use

of tools or aids during calls

4= Expert, can educate patients, as well as, nurses about nutritional guidelines with

confidence

Q9 Where would you, as an Optum Case Management/Disease Management RN, your

manager, or anyone in employed with the host organization search to find out which current

guidelines are being followed by UnitedHealth Group?

American Heart Association

American College of Cardiology

Milliman Guidelines

Heart Failure Society of America

Knowledge Library

Any of the above

None of the above


Q10 What does the American College of Cardiology Foundation/ American Heart

Association(ACCF/AHA) use as a guideline for mg/ sodium per day for patients with Stage A

or B heart failure?

1500 mg/day

2000 mg/day

3000-4000 mg/day

No recommendations, ask physician for clarification

Unsure

Q11 What guideline recommendations does the host organization recognize as the standard

for staff to reference for self-management nutritional recommendations for chronic heart

failure patients?

American Heart Association/ American College of Cardiology

American Dietetic Association

Milliman Guidelines

Heart Failure Society of America

Any of the above

None of the above


Q12 Heart failure patients with stage C or D heart failure should limit their sodium intake to:

1500mg/day

2000mg/day

2500mg/day

Insufficient data to support a specific mg/day recommendation

3000-4000mg/day

Unsure

Q13 What is the average sodium intake in the general population?

1500-2000mg

2000-2500mg

2500-3000mg

3000-3500mg

>4000mg

Unsure

Q14 True or False: Research indicates nurses are adequately prepared as heart failure

educators.

True

False


Q15 Which of these foods is considered high sodium?

A chicken breast

Beets

Baking Power

Ham

All of the above

None of the above

Unsure

Q16 What is the sodium guideline for those with hypertension, according to ACCF/AHA?

Consume no more than 1500 mg/day




Consume no more than 3000-4000mg/day

Unsure

Q17 According to the ACCF/AHA, how much fluid is acceptable for an advanced HF patient,

(stage D) to consume in a 24-hr period?

1.5-2 gallons/day

1-1.5 liters/day

1.5-2 liters/day

Tailored per doctor recommendation only

2.5 liters/day

Unsure


Appendix B

INFORMED CONSENT FORM

Western Governors University

Masters Registered Nurse Case Manager Knowledge of Evidence-Based Nutritional

Recommendations for Heart Failure Brittany Rose BSN, RN, CCM

Introduction: You are invited to participate in a research project being conducted by a

Graduate Student from Western Governors University, Brittany Rose BSN, RN, CCM. Ms.

Rose is conducting research to determine what gaps in knowledge may exist among the

Registered Nurses employed as telephonic Case Managers and Disease Managers, within the

host organization, regarding the most up to date evidence-based, nutritional guidelines for heart

failure (HF) patients.

Description of the project: Aiming to identify: What are the perceived barriers for RNs that are interfering with the

ability to provide the most current evidence-based, self-management, nutritional

recommendation guidelines to heart failure patients?

Involves answering a total of 19 multiple-choice questions, six of those are demographic

questions

Reviewing this informed consent and completion of the study combined will take

approximately 15 minutes, if you cannot complete now you may forward the email to

your home email and the link will work from any computer/mobile device

Benefits and Risks of this study: There are no direct benefits to the participants or the organization, other than possible identified

knowledge deficits that the organization can reference when reviewing educational needs for

staff. There no risks associated with participation in this study. Confidentiality: All participants of research study will remain anonymous to researcher via

the Qualtrics® program anonymity feature. Promise to participants that be no names or any

identifying personal information used or collected in this research study. It would not be

possible for the researcher to discover participant identity at any point in time. There is no

contact with participants or potential participants outside of the email request to complete the

questionnaire.

Voluntary participation and withdrawal: Participation is voluntary and refusal to

participate involves no penalties or punishments. Participants may withdraw at any time by

choosing not to complete questionnaire and there will be no repercussions for doing so.


Questions, Rights and Complaints: You may contact Ms. Rose with any questions

or concerns about participation or the study itself via work email: [email protected];

school email: [email protected], or personal cell phone: 314-435-6292. The participant may request a copy of the results of the study after they are published and should

contact the researcher for the information.

Electronic Consent Statement: I confirm I have reviewed the above information and

that by clicking this link accessing the questionnaire I am giving consent of my participation,

acknowledging that the link acts as my signature. I am fully aware that my responses will be

included in the research project entitled, “Registered Nurse Case Manager Knowledge of

Evidence-Based Based Nutritional Guideline Recommendations for Heart Failure” being

performed by graduate student Brittany K. Rose BSN, RN, CCM through Western Governors

University.

By clicking “Next”, you are agreeing that you have read the above information and that you are

voluntarily participating in this research study. Moving forward to complete the survey implies

consent. If you do not wish to participate, please close this window.

Thank you.

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