Effects of perceived self-efficacy and functional status on depression in patients with chronic heart failure

Appreciating the links between heart failure and depression

Depression and heart failure frequently occur together, symptoms overlap and the prognosis is worsened. Both conditions share biopsychosocial risk factors and are accompanied by behavioural/lifestyle, neurohormonal, inflammatory and autonomic changes that are implicated aetiologically. Depression has been conceptualized as a decompensated response to allostatic overload, wherein adaptive psychological, behavioural and physiological responses to chronic and/or severe stress, become unsustainable. Heart failure can similarly be viewed as a decompensated response to circulatory overload, wherein adaptive functional (neurohormonal effects on circulation, inotropic effects on heart) and structural (myocardial remodelling) changes, become unsustainable. It has been argued that the disengaged state of depression can initially be protective, limiting an individual's exposure to external challenges, such that full recovery is often possible. In contrast, heart failure, once past a tipping-point, can progress relentlessly. Here, we consider the bidirectional interactions between depression and heart failure. Targeted treatment of depression in the context of heart failure may improve quality of life, yet overall benefits on mortality remain elusive. However, effective treatment of heart failure typically enhances function and improves key psychological and behavioural determinants of low mood. Prospectively, research that examines the mechanistic associations between depression and heart failure offers fresh opportunity to optimize personalized management in the advent of newer interventions for both conditions.

A Scoping Review of Predictors Associated with Self-Efficacy Among Patients with Coronary Heart Disease

Self-efficacy (SE) is the main predictor of self-care behaviour in patients with coronary heart disease (CHD). Several studies identified factors that influence SE in CHD patients. However, review studies have yet to synthesize these results systematically. This review aims to identify SE and the factors influencing SE in CHD patients. This scoping review is reported based on the PRISMA Extension for Scoping Reviews (PRISMA-ScR). We searched using relevant keywords using five databases: CINAHL Plus with Full Text and Academic Search Complete, PubMed, ScienceDirect, Scopus, Taylor and Francis, and one search engine: Google Scholar, which was accessed on June 23, 2023. Articles with an observational design were included without date restrictions. The quality of evidence was assessed using the Joanna Briggs Institute critical appraisal checklist, and data synthesis used thematic analysis. We found 11 articles discussing SE and the factors influencing SE in CHD patients. In this review, most studies reported that the SE level of CHD patients tends to be low to moderate. Factors associated with SE in this population are classified into three categories (low, moderate, and high). Cardiac knowledge and patient activation are the most influential predictors of SE in CHD patients. Public health interventions such as raising awareness about heart disease, modifying health behaviours, early screening, diagnosis, and appropriate treatment are critical to improving SE and cardiac care outcomes.

Virtual reality psychological intervention helps reduce preoperative anxiety in patients undergoing carotid artery stenting: a single-blind randomized controlled trial

Objective

This study aimed to explore the effectiveness and applicability of a psychological intervention using virtual reality (VR) to reduce preoperative anxiety in patients undergoing carotid artery stenting (CAS).

Methods

A total of 114 patients aged 18-86 years who were scheduled to undergo CAS were randomized to the VR and control groups. Patients in the VR group used a VR headset to view a 16-min psychological intervention video, while those in the control group used a tablet for viewing. The primary assessment instrument was the State Anxiety Inventory (S-AI), which was given 20 min before and after the intervention and 24 h after surgery. Secondary assessment tools were the Self-efficacy for Managing Chronic Disease (SEMCD-6) scale, which was completed before the intervention and 24 h after the operation, a smart bracelet to assess sleep quality, monitored in the evening before the operation, and the VR Suitability and Satisfaction Questionnaire, completed 24 h after the operation.

Results

The two groups were similar in terms of demographic information, preintervention STAI scores and preintervention SEMCD-6 scores (p > 0.05). S-AI scores were lower in both groups after the intervention and surgery, and the scores of the VR group were lower than those of the control group (p = 0.036, p = 0.014). SEMCD-6 scores post-surgery had improved in both groups, but the VR group had significantly higher scores than the control group (p = 0.005). Smart bracelet measurements showed no significant differences in postintervention sleep quality between the two groups (p = 0.540). For satisfaction, the VR group scored higher in all aspects except scheduling. A total of 47 (85.45%) patients reported having a comfortable experience, and only 5 (9.09%) experienced mild adverse effects.

Conclusion

The use of a virtual reality psychological intervention was beneficial to reduce the anxiety of patients before CAS and improved their self-efficacy. As virtual reality devices evolve and demonstrate better comfort and safety, more comprehensive and in-depth research of the use of VR to reduce patient anxiety should be performed in the future.Clinical trial registration:https://www.chictr.org.cn/showproj.aspx?proj=186412, identifier ChiCTR2200066219.

A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population

Health care systems have made concerted efforts to improve value for individuals with complex and chronic disease. Despite these efforts, this population (and the Medicaid population in particular) has been historically difficult to impact as many members are disproportionately impacted by social determinants of health that interfere with their ability to engage the health care system effectively. Transactional, solutions-based interventions to resolve barriers to care have been ineffective at either improving outcomes or reducing cost in the long term. The authors identify 3 core barriers that prevent time-limited, transactional interventions from effectively solving complex health and social problems: trust, self-efficacy, and complexity. By evolving from a transactional framework to a relational framework, case managers can develop relationships with clients that will help overcome these barriers. More specifically, clinical case management can be utilized to resolve these barriers by implementing a long-term, relational approach with clients through 5 key principles: ensuring continuity of care, leveraging the case management relationship, titrating support and structure, engaging flexibility, and facilitating patient resourcefulness. This article discusses how these principles resolve the identified barriers and how such a model is currently being executed in University Hospital's system. RWJF Grant I.D Number is 98426.

Effects of high-quality nursing care on psychological outcomes in patients with chronic heart failure

BACKGROUND

This study will assess the effects of high quality nursing care (HQNC) on psychological outcomes (PCO) in patients with chronic heart failure (CHF).

METHODS

We will carry out a through search in 7 databases: PUBMED, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, WANGFANG, and China National Knowledge Infrastructure. Eligibility criteria will be randomized controlled trials on assessing effects of HQNC on PCO in patients with CHF. Cochrane risk of bias evaluation will be utilized for methodological quality.

RESULTS

This proposed study will summarize a rational synthesis of current evidence for HQNC on PCO in patients with CHF.

CONCLUSION

The results of this study will provide convinced evidence for judging the effects of HQNC on PCO in patients with CHF.

Socio-clinical variables affecting the level of self-care in elderly patients with heart failure

BACKGROUND

Promoting self-care is the cornerstone of heart failure management. The number of hospitalizations and unscheduled visits could be reduced in elderly patients with heart failure by the patients' active involvement in self-care.

AIMS

The aim of this study was to measure the level of self-care in elderly patients with heart failure, to examine the influence of socio-clinical variables on the level of self-care, and identify the socio-clinical variables that are predictors of self-care.

METHODS

The study included 100 heart failure patients (48 female, 52 male) aged between 60 and 88 years, treated at the Oleśno Health Care Center (Poland). The European Heart Failure Self-care Behavior Scale-9 and Mini-Mental State Examination were used.

RESULTS

The total classic European Heart Failure Self-care Behavior Scale-9 score was 22.76 points (standard deviation=8.49), and the standardised European Heart Failure Self-care Behavior Scale-9 score was 61.78 (standard deviation=23.59). Patients who were in a relationship, did not take digoxin or diuretics, were in New York Heart Association classes I and II, and had normal scores or cognitive impairment in the Mini-Mental State Examination, had significantly higher levels of self-care. Self-care was also correlated with patient age (r_s=-0.36, p<0.001) and left ventricle ejection fraction (r_s=0.23, p=0.019). Linear regression analysis demonstrated that only the New York Heart Association class has a significant impact on European Heart Failure Self-care Behavior Scale-9 scores. Compared to classes I and II, New York Heart Association class IV decreases the standardised European Heart Failure Self-care Behavior Scale-9 score by a mean of 23.60 points.

CONCLUSIONS

Intensified self-care education should be provided to patients living alone, taking digoxin and diuretics, suffering from moderate dementia, and classified in New York Heart Association class IV. These patients may require specific educational strategies to gain the knowledge required for effective self-care.

Depression in Community-Dwelling Elderly Patients With Heart Failure

The present cross-sectional study discussed the relationship between comorbid depression, demographic characteristics, clinical characteristics, and dietary self-efficacy among Taiwanese community-dwelling elderly patients with heart failure (HF). Specifically, the study examined 175 community-dwelling elderly patients with HF between July 2013 and June 2014. In total, 47.13% of the patients exhibited symptoms of depression. Those without a spouse, who were currently employed, who had an ejection fraction <30%, who had been readmitted to the hospital 2 or more times, and who had a high level of HF symptom distress were significantly more likely to be depressed. Therefore, it is crucial that care programs designed for these patients include the self-management of HF symptoms, psychological consultations, cognitive behavioral therapy, and physical exercise.

Heart Failure and Exercise: A Narrative Review of the Role of Self-Efficacy

Chronic heart failure (CHF) is a common, debilitating condition associated with significant health and economic burden. CHF management is multidisciplinary, however, achieving better health relies on a collaborative effort and patient engagement in self-care. Despite the importance of self-care in CHF, many patients have poor adherence to their medical and lifestyle regimens, in particular with regards to engaging in physical exercise. The patient's confidence in their ability, otherwise known as self-efficacy, is an important determinant of CHF health outcomes, most likely due to its effect on the uptake of CHF self-care activities especially exercise initiation and maintenance. Self-efficacy is responsive to experience such as exercise training, however the critical components of exercise interventions to improve self-efficacy have yet to be determined. This narrative review provides an overview of the role of self-efficacy in exercise adherence in CHF.

Effect of Treadmill Testing and Exercise Training on Self-Efficacy in Patients with Heart Failure

Background: Self-efficacy is a person's confidence in being able to successfully perform a specific activity or behavior. Self-efficacy has been shown to influence exercise capacity in patients post myocardial infarction, but has not been fully explored in patients with heart failure (HF). This study examined the impact of performance of a single treadmill exercise test and participation in a 3-month program of walking and resistance exercise on self-efficacy in HF patients.

Methods: 24 patients were randomized to either a home-based walking and resistance exercise program or usual care for 3 months. Prior to enrollment into the exercise program all participants performed a single treadmill exercise test with respiratory gas analysis. Self-efficacy questionnaires were completed at 3 time points, 1) prior to performance of an exercise treadmill test; 2) immediately after completing an exercise test; and 3) at the end of a 3-month exercise program.

Results: Self-efficacy for walking ( p = 0.07), climbing ( p = 0.17), lifting ( p = 0.73) and general activity ( p = 0.15) did not improve after performance of a single treadmill exercise test and usual care. However, self-efficacy for walking increased after 3 months of a walking and resistance exercise program. ( p = 0.04).

Conclusions: The findings from this study suggest that in patients with stable mild to moderate heart failure, self-efficacy is improved with participation in a home-based walking and endurance exercise program. Self-efficacy is not enhanced by performance of a single treadmill exercise test and usual care.

Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure

BACKGROUND

Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure.

AIMS

To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure.

METHODS

A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS).

RESULTS

Cronbach's alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22-.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman's rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t(318) = -5.05, p < .001) supported construct validity.

CONCLUSION

The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.

Clinical and sociodemographic factors in a sample of older subjects experiencing depressive symptoms

OBJECTIVES

This study aims to determine the frequency of clinically significant depressive symptoms (CSDS) in a community sample of older Brazilians and to examine their relationship with sociodemographic factors, cognitive and functional impairment (CFI), and medical illness.

METHODS

A total of 1145 subjects aged 60 years or older living in the City of Ribeirao Preto, State of Sao Paulo, Brazil, were interviewed. The following instruments were used: a 10-item scale for screening of depressive symptoms in older people, the mini mental state examination, the Fuld object memory evaluation, the informant questionnaire on cognitive decline in the elderly, the Bayer activities of daily living scale, and a sociodemographic and clinical questionnaire.

RESULTS

The frequency of CSDS was 15.7%. Logistic regression analysis indicated that being previously depressed, having CFI, having lower level of education, using psychotropics, and not engaging in physical exercise were related to CSDS. On the other hand, being a woman, older, medically ill, employed, or married was not associated with CSDS.

CONCLUSIONS

Consistent with previous reports, lower education, lack of physical activity, and CFI were significantly associated with higher frequencies of CSDS. Further investigations are necessary to clarify the occurrence of depression and possible modifiable factors in developing countries such as Brazil.

Reliability and validity of the continence self-efficacy scale in Turkish women with urinary incontinence

This study investigated the psychometric properties of the Continence Self-Efficacy Scale. Data was collected from 128 women who had urinary incontinence using the following instruments: the Continence Self-Efficacy Scale, the Broome Pelvic Muscle Exercise Self-Efficacy Scale, the International Consultation on Incontinence Questionnaire Short Form, and the Beck Depression Inventory. The validity of the Continence Self-Efficacy Scale was investigated using confirmatory factor analysis and convergent and divergent validity analyses. The reliability of the Continence Self-Efficacy Scale was examined in terms of internal consistency and test-retest correlations. Confirmatory factor analysis indicated a three -factor model that had acceptable goodness-of-fit indices. The convergent validity of the Continence Self-Efficacy Scale was supported by a positive correlation between the Continence Self-Efficacy Scale and the Broome Pelvic Muscle Exercise Self-Efficacy Scale. The divergent validity of the Continence Self-Efficacy Scale was supported by negative relationships between the Continence Self-Efficacy Scale and the Beck Depression Inventory. The Cronbach's alpha values regarding internal consistency were 0.94 for the overall scale and 0.92-0.93 for the subscales. Test-retest correlations were 0.75 for the overall scale and 0.52-0.74 for the subscales. The Continence Self-Efficacy Scale is a valid and reliable instrument for use in Turkish women with urinary incontinence.

Illness Intrusiveness Mediates the Relationship Between Heart Failure Severity and Depression in Older Adults

Depression frequently co-occurs in heart failure (HF) patients, causing significant interference and negative health outcomes. This case-controlled study explored the construct of illness intrusiveness and examined its relationship to HF severity and depression. Older veterans ( n = 104) with an HF diagnosis completed a one-time assessment that included demographics, depressive symptoms (Geriatric Depression Scale), the Illness Intrusiveness Rating Scale (IIRS), and HF quality of life and functional abilities (Kansas City Cardiomyopathy Questionnaire [KCCQ]). Analyses included exploratory correlations between IIRS and KCCQ items, a confirmatory factor analysis (IIRS), and formal mediational analyses. Results indicated that the IIRS had adequate internal consistency and concurrent validity, with support for its established three-factor model. Regression analyses indicated that illness intrusiveness mediated HF illness severity and depression. In conclusion, illness intrusiveness may be a better indicator of depression than illness severity (HF symptoms); thus research methods and interventions targeted at reducing illness intrusiveness merit further investigation.

Testing a model of patient characteristics, psychologic status, and cognitive function as predictors of self-care in persons with chronic heart failure

OBJECTIVE

Self-care is a key component in the management of chronic heart failure (CHF). Yet there are many barriers that interfere with a patient's ability to undertake self-care. The primary aim of the study was to test a conceptual model of determinants of CHF self-care. Specifically, we hypothesized that cognitive function and depressive symptoms would predict CHF self-care.

METHODS

Fifty consecutive patients hospitalized with CHF were assessed for self-care (Self-Care of Heart Failure Index), cognitive function (Mini Mental State Exam), and depressive symptoms (Cardiac Depression Scale) during their index hospital admission. Other factors thought to influence self-care were tested in the model: age, gender, social isolation, self-care confidence, and comorbid illnesses. Multiple regression was used to test the model and to identify significant individual determinants of self-care maintenance and management.

RESULTS

The model of 7 variables explained 39% (F [7, 42] 3.80; P = .003) of the variance in self-care maintenance and 38% (F [7, 42] 3.73; P = .003) of the variance in self-care management. Only 2 variables contributed significantly to the variance in self-care maintenance: age (P < .01) and moderate-to-severe comorbidity (P < .05). Four variables contributed significantly to the variance in self-care management: gender (P < .05), moderate-to-severe comorbidity (P < .05), depression (P < .05), and self-care confidence (P < .01). When cognitive function was removed from the models, the model explained less of the variance in self-care maintenance (35%) (F [6, 43] 3.91; P = .003) and management (34%) (F [6, 43] 3.71; P = .005).

CONCLUSION

Although cognitive function added to the model in predicting both self-care maintenance and management, it was not a significant predictor of CHF self-care compared with other modifiable and nonmodifiable factors. Depression explained only self-care management.

Impact of depression on quality of life assessment in heart failure

BACKGROUND

Depression is highly prevalent in patients with chronic heart failure (CHF) and may bias patients' reports of their health-related quality of life (HRQoL). Depressed patients may rate their limitations of HRQoL worse even when their condition is rather good. We aimed to examine whether co-morbid depression alters the relationship between disease severity and HRQoL, thus compromising the validity of a CHF-specific HRQoL measure.

METHODS

A sample of 233 outpatients with CHF (mean age 64.5 years, 70% male) was evaluated. Depression was measured with the Patient Health Questionnaire and CHF-specific HRQoL with the Kansas City Cardiomyopathy Questionnaire (KCCQ). CHF severity was assessed with physician ratings of the New York Heart Association (NYHA) functional class.

RESULTS

Both NYHA functional class and depression independently impacted the various subscales of the KCCQ. Regarding the symptom- and function-related subscales, a dose-response relationship between disease severity and HRQoL was observed also in depressed patients. In contrast, in the quality of life subscale covering life satisfaction an interaction effect of disease severity and depression was found. In this subscale, a dose-response relationship between increasing disease severity and worsening HRQoL was no longer present among the depressed.

CONCLUSIONS

Both disease severity and depression impacted each heart failure-specific HRQoL dimension while the presence of depression seemed to distort the relationship between disease severity and HRQoL in the quality of life subscale. As quality of life may depend more on the presence of depression than on the severity of CHF, assessing depression may help interpreting HRQoL scores.

A critical review of appropriate conceptual models for use by coronary care nurses

BACKGROUND

There is little evidence of the extent of conceptual model use within cardiovascular nursing. Concern exists within nursing that nursing theory and conceptual model use within practice is less than optimal. It is further suggested that there is little evidence of nursing theory occupying its true position as the central tenet of nursing practice and cardiovascular nurses have been challenged to reconsider this aspect of practice.

AIM

The aim of this review is to explore the effectiveness of conceptual models used within cardiovascular nursing to further explore their potential benefit.

METHODS

Using key terms, a search was conducted using electronic databases CINAHL and PUBMED; yielding seven papers that fulfilled selection criteria.

FINDINGS

Few papers related to research studies in the area. However, of those identified significant examination and testing of concepts emerged within the studies. Rather than merely using concepts as an organizing framework or a component of the study, theories alluded to were scrutinized and consistently applied. Although studies identified mostly referred to specific testing and examination of aspects of conceptual models, the notion of self-care and support for clients emerges as a strong theme within the review. The relationship between nurse and client seemed to be pivotal in any noted improvements.

CONCLUSIONS

The findings have limited application to practice. In the absence of large-scale longitudinal studies, only selected aspects of conceptual models or theory were scrutinized. Further research is required in this area to identify conceptual models of nursing that are most appropriate for cardiovascular nursing care.

Effects of self-efficacy, self-care behaviours on depressive symptom of Taiwanese kidney transplant recipients

AIMS

The aim of this study was to examine the effect of self-efficacy on depression and to consider the mediating effect of self-care behaviour.

BACKGROUND

Depression is a problem for kidney transplant recipients and can compromise their quality of life. From other studies on chronic illnesses, self-efficacy and self-care behaviour have been considered to be potential determinants for depressive symptoms. However, none of these previous studies have investigated the relationships among these variables in kidney transplantation recipients.

DESIGN

A cross-sectional survey employing correlation design and purposive sampling was used.

METHODS

One hundred and seventy-seven persons who had received a kidney transplant participated. A self-administrated questionnaire and a medical record audit were used to collect data. The data were analysed using correlation and hierarchical linear regression methods.

RESULTS

The average score of depressive symptoms was 8.61 SD 7.64. Among the participants in the study, 32.8% had scores of depressive symptoms higher than 11 (indicating mild to severe symptoms of depression). Self-efficacy and self-care behaviour had direct negative effects on depressive symptoms. Self-care behaviour had partial mediating effect on the relationship between self-efficacy and depression. Total variance explained was 23%.

CONCLUSION

Depressive symptoms are still a problem that need to be addressed among kidney transplantation patients. Patients who have higher self-efficacy and higher self-care behaviour will have lower depressive symptoms. Our results support that self-efficacy is the significant predictor of depressive symptoms.

RELEVANCE TO CLINICAL PRACTICE

Self-efficacy is a powerful and modifiable determinant of depressive symptoms. We should design interventions that focus not only on the skill aspects of self-care behaviour but also on those that have a strong connection with self-efficacy. We could incorporate the self-efficacy-enhanced strategies as proposed by social cognitive theory into the kidney transplantation care programme.

Reliability and validity of the Exercise Self-Regulatory Efficacy Scale for individuals with chronic obstructive pulmonary disease

BACKGROUND

Exercise has important benefits for individuals with chronic obstructive pulmonary disease (COPD). However, to sustain long-term benefits of exercise, adherence is needed. Adherence requires self-regulation. No scale is available to measure exercise self-regulation in individuals with COPD.

OBJECTIVES

We developed and tested the reliability and validity of an "Exercise Self-Regulatory Efficacy Scale (Ex-SRES)" for individuals with COPD.

METHODS

A convenience sample of 109 subjects with COPD was recruited. Cronbach's alpha was used to assess the internal consistency reliability of the Ex-SRES. Subjects' exercise behaviors and health status were used to assess the validity of the Ex-SRES.

RESULTS

The Ex-SRES demonstrated evidence of reliability (Cronbach's alpha .917) and validity (correlation with minutes of exercise per week [r = .41; P < .0001] and health status [r = .37; P < .0001]).

CONCLUSION

The Ex-SRES is a short (16-items) and easy to use questionnaire that may be valuable for assessing patients in clinical settings, as well as for future research studies in behaviors related to exercise.

Consequences and Predictors of Depression in Patients With Chronic Heart Failure: Implications for Nursing Care and Future Research

Depression is common among patients with chronic heart failure (HF) and leads to more symptoms of HF, decreased quality of life, and an increased risk for premature death. Depressed HF patients also use more health care resources, which increases the economic burden on the health care system. The assessment of risk factors of depression such as age younger than 60-65 years, poor physical functioning, previous depression, poor self-efficacy, living alone, and distressful relationships, in combination with the use of depression instruments, can be helpful in detecting depression in HF patients. Unfortunately, interventions on how to relieve depression in patients with HF have not been investigated thoroughly; however, depression agents as well as HF education, social support, exercise therapy, stress management, and relaxation have been shown to be useful interventions. Because of poor outcomes, studies that examine the effectiveness and/or side effects of pharmacologic as well as nonpharmacologic interventions on depressed patients with HF are needed.

The measurement and prevalence of depression in patients with chronic heart failure

Chronic heart failure is a common disease accompanied by poor mental health and depression. The diagnosis of depression is based on the presence of affective, cognitive, and somatic symptoms assessed by categoric or dimensional instruments. Depression is prominent and high rates are found with dimensional instruments in hospitalized heart failure patients. Categoric instruments seem to be more reliable but are more complex to use. Because of poor outcomes, attention should also be paid to subthreshold depression. In screening for such cases, dimensional instruments might be preferable because of the risk for underestimation by categoric instruments. Dimensional instruments might also be easier to implement in daily practice but, to reduce bias, cutoff scores might need refinement according to the clinical setting. Therefore, studies that evaluate different cutoff values are needed to find a critical level of burden from a depressive symptomatology on outcomes such as mortality, hospitalizations, and quality of life.

Conceptual models used by nurses working in coronary care units--a discussion paper

In the UK, Europe and the USA conceptual models of nursing are features of many undergraduate nursing curricula [Alligood MR. The nature of knowledge needed for nursing practice. In Alligood MR, Marriner-Tomey A, editors. Nursing theory utilisation and application. London: Mosby, 2002, Tierney AJ. Nursing models extant or extinct? J Adv Nurs 1998;8(1):77-85] and commonly used in practice. However, UK nurses in practice continue to be dissatisfied with conceptual model use [Griffiths P. An investigation into the description of patients' problems by nurses using two different needs-based nursing models. J Adv Nurs 1998;28(5):969-977, Mason C. Guide to practice or 'load of rubbish'? The influence of care plans on nursing practice in five clinical areas in Northern Ireland. J Adv Nurs 1999;29(2):380-387, Murphy K, Cooney A, Casey D, Connor M, O'Connor J., Dineen B. The Roper, Logan and Tierney Model: perceptions and operationalization of the model in psychiatric nursing within one health board in Ireland. J Adv Nurs 2000;31(6):1333-1341]. An association with increased paperwork and documentation together with a belief that these abstract concepts do not quite fit with the practice setting has resulted in a generalised apathy towards their use in some areas [Timmins F. Critical care nursing in the 21st Century. Intensive Crit Care Nurs 2002;18:118-127]. In an era of concerns about both cost and quality, together with an increased impetus towards multi-professional working patterns and role expansion, alternative models of care, such as critical pathways and care pathways are gaining increased favour in the clinical setting [Johnson S, editor. Pathways of care. Oxford; Blackwell Science 1997]. The aim of this paper is to consider whether or not the traditional conceptual models of nursing are apt for today's practicing coronary care nurse. Specific questions to be addressed are: what is the research evidence that informs conceptual model use in coronary care and what are the conceptual models that commonly inform contemporary practice in coronary care nursing? Suggested ways forward for conceptual model use within nursing are also proposed.

The Smallpox Vaccine: A Multidimensional Model of Choice

Following September 11, 2001, the U.S. government increased its efforts to prepare for future attacks, including those using dangerous biological agents such as smallpox. The smallpox vaccination program called for vaccinating military personnel and smallpox response teams, including healthcare workers and other first responders. The program of vaccinating healthcare workers was largely unsuccessful; few individuals volunteered to be vaccinated, highlighting the importance of understanding the factors that influence choice regarding this complex medical decision. This study examined stated choice and how it was associated with risk perceptions, knowledge, psychological distress, and general vaccine beliefs using a five-dimensional choice model. The model used multivariable modeling strategies in a sample of 256 undergraduate, graduate, and medical students. Sixty-three percent of the sample stated that they would elect to receive the smallpox vaccination. Multiple factors were related to stated choice in multivariable models, including perceived risk/worry, general vaccine beliefs, decisional conflict, and gender. However, the models were more successful at predicting acceptance of the vaccination than vaccine refusal. Although support was obtained for a multidimensional model of choice, several questions were raised by our results, including (a) whether refusal of smallpox vaccination can be more effectively characterized, possibly with additional questions; (b) whether the model translates to actual vaccination behavior; and (c) whether the model describes choice in more at-risk samples (e.g., first responders, healthcare workers). A multidimensional modeling approach should facilitate these and other studies of choice.

Depression and Anxiety in Heart Failure

BACKGROUND

Although common among patients with heart failure, depression and anxiety have been relatively neglected by researchers and practitioners. Both depression and anxiety have been implicated in contributing independently to the poor outcomes seen in patients with heart failure. Emphasis in the literature is on physical symptom recognition and management, in contrast to the patient's perspective of the effects of heart failure on his or her daily life.

METHODS AND RESULTS

This review summarizes and integrates research findings on anxiety and depression and translates these findings to clinical practice. Depression and anxiety are prevalent among patients with heart failure and require assessment and intervention. Short-term nonpharmacologic approaches, in conjunction with drug therapy, hold promise for successful management of patients who are depressed or anxious.

CONCLUSION

Carefully designed clinical trials that are tailored to individual needs, yet are embedded within a systemic framework, are needed to inform clinicians regarding optimal practices for the treatment of patients with heart failure who suffer from depression or anxiety.

Depression in patients with heart failure

BACKGROUND

Psychologic comorbidities, particularly depression, often accompany heart failure and add to the complexity of clinical management. We conducted a study to describe the prevalence of depression, the differences between patients with minimal versus mild to severe depression, and the correlates of depression in patients with heart failure.

METHODS AND RESULTS

Data were collected from 200 patients with symptoms of heart failure resulting from systolic dysfunction. Psychologic assessment included depression, perceived control, neuroticism, educational needs, and social support/network. Patients were, on average, 57.0 (+/-12.1) years old, male (168, 84.0%), and in New York Heart Association (NYHA) class II or III (n=140, 70.0%) with a mean ejection fraction of 25.5+/-6.4%. They had an average maximal oxygen uptake of 15.8 (+/-4.6) mL x kg x min and 6-minute walk distance of 1345.0 (+/-302.1) feet. Minimal depression was described by 105 (52.5%) patients, mild by 62 (31%), moderate by 30 (15%), and severe by 3 (1.5%). The significant differences between patients with minimal depression compared to mild to severe depression were NYHA class (chi2=14.05, P=.003), maximal oxygen uptake (t=2.62, P=.010), 6-minute walk distance (t=4.22, P < .001), beta-blocker therapy (chi2=15.21, P < .001), perceived control (t=7.93, P < .001), and neuroticism (t=-8.85, P < .001).

CONCLUSIONS

More than half the patients studied did not report experiencing significant depression. In those who did, both physical and psychosocial variables accounted for 48.6% of the variance. These findings warrant further research and indicate a need to test interventions aimed at enhancing perceived control, reducing neuroticism, and meeting educational needs to reduce depression in patients with heart failure.

Correlates of psychological distress in elderly patients with congestive heart failure

OBJECTIVE

High levels of psychological distress have been reported in patients with congestive heart failure (CHF), resulting in increased morbidity and mortality. Yet, little is known about its associated factors. The purpose of this study is to identify the significant demographic, clinical and psychosocial correlates of psychological distress in CHF patients.

METHODS

Cross-sectional data were obtained from a sample of a consecutive series of hospitalized CHF patients (n = 227) with measures of psychological distress, functional status, symptom status, social support and health perception. Objective clinical variables were obtained from the hospital records.

RESULTS

High levels of psychological distress, in particular, depression, were found in patients with CHF. In hierarchical regression analysis, poorer perceived emotional-informational support, higher levels of fatigue, poorer health perception and not living with family were identified as the significant correlates of psychological distress. These correlates, in total, explained 49% of the variance for the scores of psychological distress. None of the objective clinical variables demonstrated a significant contribution that accounted for psychological distress in CHF patients.

CONCLUSION

The findings highlight the importance of addressing social support for CHF patients. Assisting this vulnerable patient group to cope with fatigue and to cultivate a positive health perception are also highly prioritized treatment goals.