The role of self-efficacy in the self-care of patients with chronic conditions

Background. The management of chronic conditions requires that patients perform specific self-care behaviors and obtain the contribution of their families (e.g., for taking medications as prescribed and eating a healthy diet). Self-care is associated with better outcomes in chronic conditions (e.g., improved quality of life and mortality). However, patients often struggle to perform self-care. Self-efficacy, defined as the confidence to perform a certain behavior despite barriers, can improve patient self-care behaviors and the contribution of their family caregivers. However, so far, we still do not know whether patient self-efficacy can influence the relationship between family support and self-care in populations with multiple chronic conditions (MCC). Self-efficacy represents an easily targetable construct; the use of psychoeducational interventions such as motivational interviewing (MI) can improve intermediate outcomes (e.g., quality of life and self-care). However, little is known whether this intervention can also improve distal outcomes (i.e., mortality and health services use) as a result of self-care behavior change. Objective. The objective of this research program was to (i) describe the mechanism by which family support influences self-care in people with multiple chronic conditions, with particular focus on patient self-efficacy; (ii) develop an instrument to measure caregiver self-efficacy in contributing to patient self-care (CSE-CSC scale) in MCC, and (iii) investigate the influence of a MI intervention that targets self-efficacy, in improving health service use and mortality in a chronic disease population (i.e., heart failure) as a result of sustained behavior change. Methods. In the first cross-sectional study we analyzed data from the SODALITY study, which enrolled a sample of 541 older adults affected by MCC (mean age = 76.6 ± 7.3 years, 55.6% females) from seven Italian regions. Data were analyzed by descriptive statistics and a series of structural equation models. In the second cross-sectional study, we enrolled 358 caregivers (mean age = 54.6 ± 15.1 years, 71.5% females) of patients from the SODALITY study. Data were analyzed with descriptive statistics, exploratory and confirmatory factor analysis, and reliability analysis. In the third study we analyzed longitudinal data from the MOTIVATE-HF trial. Patients and caregivers were randomized to Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers) or Arm 3 (control group). months. We enrolled 510 patients (median age 74 years, 58% male) and caregivers (median age 55 years, 75% female) and we collected data at baseline and at 3, 6, 9 and 12 months. Above and beyond descriptive statistics, we performed a longitudinal generalized linear mixed model and unadjusted Cox proportional-hazards regression model. Results. In the first study depression and self-efficacy were significant mediators of the relationship between family support and self-care; however, in men, depression was not a significant mediator. In the second study, the dimensionality analysis of the CSE-CSC confirmed 2 factors within the scale. Construct validity testing showed significant correlations between the scores of the CSE-CSC scale and the scores of the Caregiver Contributions to Self-Care of Chronic Illness Inventory scales. Reliability coefficients were also satisfactory. In the third study, we found that at 12 months, 16.1%, 17% and 11.2% of patients used health-care services at least once in Arms 1, 2 and 3, respectively, without significant differences. At 3 months, 1.9%, 0.6% and 5.1% of patients died in Arms 1, 2 and 3, respectively. Mortality was lower in Arm 2 vs Arm 3 at 3 months (p=0.04), but no difference was found at subsequent follow-ups. Conclusion. This doctoral dissertation offers new knowledge on the self-efficacy construct in patients and caregivers in the context of MCC. The finding that self-efficacy is reaffirmed as essential in the dynamics of family and self-care in MCC allows us to target this construct more effectively in clinical environments. We also provided investigators with a new instrument to measure self-efficacy of the caregivers; this tool has adequate psychometric properties and is ready for use both in clinical practice and research. Finally, we provided evidence on the effectiveness of motivational interviewing on mortality in heart failure patients. Health care professionals will have stronger evidence to rely on, to incorporate MI into their interactions with patients. These results contribute to advancing the science of family nursing in HF self-care

A Middle-Range Theory of Social Isolation in Chronic Illness

: Chronic illnesses and social isolation are major public phenomena that drive health and social policy worldwide. This article describes a middle-range theory of social isolation as experienced by chronically ill individuals. Key concepts include social disconnectedness, loneliness, and chronic illness. Antecedents of social isolation include predisposing factors (e.g., ageism and immigration) and precipitating factors (e.g., stigma and grief). Outcomes of social isolation include psychosocial responses (e.g., depression and quality of life), health-related behaviors (i.e., self-care), and clinical responses (e.g., cognitive function and health service use). Possible patterns of social isolation in chronic illness are described

The Influence of Caregiver Contribution to Self-care on Symptom Burden in Patients With Heart Failure and the Mediating Role of Patient Self-care

background: patients with heart failure experience high symptom burden, which can be mitigated with adequate self-care. caregiver contribution to self-care has been theorized to improve patient symptom burden. the mediating role of patient self-care in this relationship has not been tested yet. objectives: the aim of this study was to test whether (a) caregiver contribution to self-care influences patient self-care, (b) patient self-care influences symptom burden, and (c) patient self-care mediates the relationship between caregiver contribution to self-care and symptom burden. methods: In this study, the authors conducted a secondary analysis of the baseline and 3-month data from the MOTIVATE-HF trial, which enrolled 510 dyads (patient with heart failure and caregiver) in Italy. multigroup confirmatory factor analysis was used to test measurement invariance. autoregressive longitudinal path analysis with contemporaneous mediation was used to test our hypotheses. results: on average, caregivers were 54 years old and mainly female, whereas patients were 72.4 years old and mainly male. better caregiver contribution to self-care maintenance was associated with better patient self-care maintenance (β = 0.280, P < .001), which, in turn, was associated with lower symptom burden (β = -0.280, P < .001). patient self-care maintenance mediated the effect of caregiver contribution to self-care maintenance on symptom burden (β = -0.079; 95% bias-corrected bootstrapped confidence interval, -0.130 to -0.043). better caregiver contribution to self-care management was associated with better patient self-care management (β = 0.238, P = .006). the model significantly accounted for 37% of the total variance in symptom burden scores (P < .001). conclusions: this study expands the situation-specific theory of caregiver contribution to heart failure self-care and provides new evidence on the role of caregiver contribution to self-care and patient self-care on symptom burden in heart failure

The relationship between caregiver contribution to self-care and patient quality of life in heart failure: A longitudinal mediation analysis

Background: Patients with heart failure may experience poor quality of life due to a variety of physical and psychological symptoms. Quality of life can improve if patients adhere to consistent self-care behaviors. Patient outcomes (i.e., quality of life) are thought to improve as a result of caregiver contribution to self-care. However, uncertainty exists on whether these outcomes improve as a direct result of caregiver contribution to self-care or whether this improvement occurs indirectly through the improvement of patient heart failure self-care behaviors. Aims: To investigate the influence of caregiver contribution to self-care on quality of life of heart failure people and explore whether patient self-care behaviors mediate such a relationship. Methods: This is a secondary analysis of the MOTIVATE-HF randomized controlled trial (Clinicaltrials.gov registration number: NCT02894502). Data were collected at baseline and 3 months. An autoregressive longitudinal path analysis model was conducted to test our hypotheses. Results: We enrolled a sample of 510 caregivers [mean age = 54 (±15.44), 24% males)] and 510 patients [mean age = 72.4 (±12.28), 58% males)]. Patient self-care had a significant and direct effect on quality of life at three months (β = 0.20, p < .01). Caregiver contribution to self-care showed a significant direct effect on patient self-care (β = 0.32, p < .01), and an indirect effect on patient quality of life through the mediation of patient self-care (β = 0.07, p < .001). Conclusion: Patient quality of life is influenced by self-care both directly and indirectly, through the mediation of caregiver contribution to self-care. These findings improve our understanding on how caregiver contribution to self-care improves patient outcomes

A family nurse-led intervention for reducing health services’ utilization in individuals with chronic diseases : The ADVICE pilot study

Objectives Intensive health services’ utilization is common in older individuals affected by chronic diseases. This study assessed whether a structured family nurse-led educational intervention would be effective in reducing health services’ use (readmissions and/or emergency service access) among older people affected by chronic conditions. Methods This is a non-randomized before-after pilot study. A sample of 78 patients was recruited from two general practices in Italy and 70 among them were followed for 8 months. Standard home care was provided during the first four months’ period (months 1–4), followed by the educational intervention until the end of the study (months 5–8). The intervention, based on the teach-back method, consisted of by-weekly 60-min home sessions targeting aspects of the disease and its treatment, potential complications, medication adherence, and health behaviours. Rates of health services’ use were collected immediately before (T0), and after the interventions (T1). Differences in utilization rates were examined by the McNemar’s test. Potential factors associated with the risk of health services’ use were explored with a Cox proportional hazard regression model. Results The sample (n = 78) was predominantly female (n = 50, 64.1%), and had a mean age of 76.2 (SD = 4.8) years. Diabetes mellitus was the most frequent disease (n = 27, 34.6%). McNemar’s test indicated a significant reduction in health services’ use at T1 (McNemar χ2 = 28.03, P < 0.001). Cox regressions indicated that time and patient education, as well as their interaction, were the only variables positively associated with the probability of health services’ use. Conclusion A teach-back intervention led by a family nurse practitioner has the potential to reduce health services’ use in older patients with chronic diseases

Psychometric testing of the caregiver contribution to self-care of coronary heart disease inventory

Background: Caregivers are important contributors to the self-care of patients with coronary heart disease (CHD). Aims: The aims of this study are to describe the development and psychometric properties of the caregiver contribution to self-care of coronary heart disease inventory (CC-SC-CHDI). Methods: The CC-SC-CHDI was developed from the patient version of the scale, the Self-care of Coronary Heart Disease Inventory (SC-CHDI) and translated into Italian using forward and backward translation. Baseline data from the HEARTS-IN-DYADS study were used. Confirmatory factor analysis (CFA) was conducted to assess factorial validity; Cronbach's alpha and the model-based internal consistency index were used to test internal consistency reliability, and Pearson's correlation coefficient was used to test convergent validity, by investigating the association between the CC-SC-CHDI and the SC-CHDI scores. Results: We included 131 caregivers (mean age 55 years, 81.2% females, 74% married) of patients affected by CHD (mean age 66 years, 80.2% males, 74% married). The CFA confirmed two factors in the caregiver contribution to self-care maintenance scale ("consulting behaviors" and "autonomous behaviors"), one factor for the CC to self-care monitoring scale, and two factors in the CC to self-care management scale ("consulting behaviors and problem-solving behaviors"). Reliability estimates were adequate for each scale (Cronbach's alpha and model-based internal consistency indexes ranging from 0.73 to 0.90). Significant and positive correlations were observed between CC-SC-CHDI and SC-CHDI scales. Conclusion: The CC-SC-CHDI has satisfactory validity and reliability and can be used confidently in clinical settings and research to assess caregiver contributions to CHD self-care

Learning teamworking and non-technical skills: a pilot study of a postgraduate course at the University of Florence

Abstract Background: Non-technical skills (NTS) are the cognitive and social skills that integrate the technical skills of a worker. In healthcare systems, NTS exert positive effects on patients’ safety and healthcare professionals’ efficiency. Aim: This study aims to assess the degree of NTS knowledge, before and after a workshop administered to a group of 17 nursing students attending a critical care nursing postgraduate course at the University of Florence. Methods: A cross-over design study was conducted. The workshop was composed of short lectures on “fundamentals of teamworking” and “team building and communication”, followed by team activities and gaming. At the end of the day a medical “escape room” about a shock scenario, was developed and run by the students. A questionnaire investigating participants’ entertainment and self-evaluation of NTS use, was administered at the end of the simulation sessions. Results: A sample of 17 nurses was enrolled. Pre-posttests were completed by 16 participants. Seventy-five % (n=12) of the respondents found the team working activities exciting. Most of the participants (62.5%, n=10) considered the “escape shock room game” enjoyable and stimulating and would recommend the learning activities to other healthcare professionals (75%, n=12). Compared to pre-test scores, statistically, significant improvements in NTS understanding were found on the topics of “team building” (p<0.001; r= -0.60), “teamworking” (p= 0.001; r= -0.56), “membership” (p= 0.001; r= -0.56), “hard skills” (p= 0.001; r= -0.57), “soft skills” (p=0.001; r= -0.56) and “situational awareness” (p< 0.001; r= -0.61) items. Conclusions: The process of NTS training is well accepted by critical care nursing students and can improve their competencies. Therefore, simulation based NTS training programs and gaming activities should be periodically implemented as part of Critical Care Nursing Postgraduate Courses

Adherence of systematic reviews to Cochrane RoB2 guidance was frequently poor : A meta epidemiological study

Objectives To assess whether the use of the revised Cochrane risk of bias tool for randomized trials (RoB2) in systematic reviews (SRs) adheres to RoB2 guidance. Methods We searched MEDLINE, Embase, Cochrane Library from 2019 to May 2021 to identify SRs using RoB2. We analyzed methods and results sections to see whether risk of bias was assessed at outcome measure level and applied to primary outcomes of the SR as per RoB2 guidance. The relation between SR characteristics and adequacy of RoB2 use was examined by logistic regression analysis. Results Two hundred-eight SRs were included. We could assess adherence in 137 SRs as 12 declared using RoB2 but actually used RoB1 and 59 did not report the number of primary outcomes. The tool usage was adherent in 69.3% SRs. Considering SRs with multiple primary outcomes, adherence dropped to 28.8%. We found a positive association between RoB2 guidance adherence and the methodological quality of the reviews assessed by AMSTAR2 (p-for-trend 0.007). Multivariable regression analysis suggested journal impact factor [first quartile vs. other quartiles] was associated with RoB2 adherence (OR 0.34; 95% CI: 0.16-0.72). Conclusions Many SRs did not adhere to RoB2 guidance as they applied the tool at the study level rather than at the outcome measure level. Lack of adherence was more likely among low and very low quality reviews