This study lasted for a total of three months. The purpose is to build a hospital-family transitional nursing intervention program for patients with chronic heart failure, and to explore the effectiveness of the program on the self-management of patients with chronic heart failure, in order to provide certain empirical research for the clinical intervention of transitional nursing for patients with chronic heart failure. If you have any questions or difficulties, you can withdraw from this study at any time, which will not affect your treatment and nursing. The purpose of this study is to improve your self-care level and prevent your re-admission. It will not harm your physical and mental health and will not have a negative impact on the relationship between patients and nursing. You participate in this study and The personal data in the study is confidential, and any public report on the results of this study will not disclose your personal identity.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
60
The intervention group received a transitional care intervention mainly focused on the transitional care model (TCM).
Institute of Nursing and Health, School of Nursing and Health, Henan University
Kaifeng, Henan, China
Self-efficacy management indicators
The measurement tool adopts the Chronic Disease Self-Efficacy Questionnaire compiled by Stanford University in the United States.The scoring consists of two dimensions: symptom management and disease-commonality management. The self-efficacy score for symptom management is calculated by averaging items 1, 2, 3, and 4 (if two or more items are missing or omitted, the variable is considered missing). A higher score indicates greater self-efficacy in symptom management. The self-efficacy score for disease-commonality management is obtained by averaging items 5 and 6. The score ranges from 1 to 5, a higher score indicates higher self-efficacy in disease-commonality management.
Time frame: Baseline, one month, three months
Self-care indicators
In this study, the Chinese version of the self-care ability scale for elderly, translated by Guo , was used. The scale demonstrates good reliability and validity, with a Cronbach's α coefficient of 0.82, a test-retest reliability of 0.82, and a content validity index of 0.94. The scale consists of 17 items and is applicable to all older adults. Scoring on the scale ranges from "completely disagree" to "completely agree," with scores ranging from 1 to 5. Higher scores indicate a higher self-care ability in older adults.
Time frame: Baseline, one month, three months
Disease-related indicators
Disease-related indicators are the indicators of frequent examination of patients with heart failure in the hospital: The blood test index adopts NT-proBNP as a measurement indicator, which is an independent risk factor for the death and re-admission of patients with heart failure. Due to structure and metabolism, NT-pro BNP has the advantages of long half-life (120min), high blood concentration, low individual variability rate, good in vitro stability, not limited by specimen collection conditions and the influence of specimen type (plasma or serum). NT-pro BNP testing on patients can help assess long-term risks. Repeated determination will provide more prognostic information for patients.
Time frame: Baseline, one month, three months
Transitional nursing evaluation indicators
This study adopts the Care Transitions Measure (CTM-15) developed by American scholar COLEMAN in 2002. This scale is a self-assessment scale that evaluates transitional care from the patient's perspective, including information transmission ( 6 items), patient participation (3 entries), management preparation (4 entries), nursing plan (2 entries) 4 dimensions, a total of 15 entries. The results show that the total scale Cronbach's α coefficient is 0.93, and the content validity index is 0.99, which has good credibility. The scores of each item: "very disagree", "disagree", "agree" and "very agree" are 1\~4 points respectively, and the final score is converted to 0\~100 points. The higher the score, indicating that the research subjects are satisfied with the transitional nursing services.
Time frame: Baseline, one month, three months
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