Heart failure represents a major public health challenge in Saudi Arabia

Theoretical Subtraction: Heart Failure

With the current high prevalence of heart failure (HF), self-care deficits constitute a significant driver of poor prognosis and reduced quality of life in this population. Specifically, inadequate self-care capacities underlie high hospital readmission rates of 30-37% within 30 days after discharge for Saudi HF patients (Aljabri, 2021; Alshibani et al., 2020). Effective self-care encompasses the daily behaviors and lifestyle adjustments needed to maintain physiological stability and prevent acute decompensation events in HF. Key components associated with this issue include adhering to complex medication and dietary regimens, frequent symptom monitoring, prompt decision-making for seeking care when symptoms exacerbate, and ongoing adjustments to activity levels based on HF status (Zisis et al., 2021). However, research shows that motivational, knowledge-based, and skill-based barriers frequently interfere with HF patients’ ability to perform adequate self-care (Negarandeh et al., 2020). As conceptualized within Orem’s nursing self-care deficit theory guiding this study, these unmet self-care requisites constitute care deficits requiring tailored nursing interventions (Mesbahi et al., 2020). The factors contributing to poor self-care capacities in Saudi HF patients include inadequate health literacy regarding the disease, cultural beliefs about illness causation that influence treatment adherence decisions, and the inability to recognize subtle symptom changes that require clinical follow-up (Mujamammi et al., 2020). Therefore, this study aims to develop and evaluate a comprehensive Saudi HF self-care educational intervention tailored to address cultural needs and barriers within this population. The intervention consists of in-hospital education focused on teaching HF self-care skills paired with 30-day telephone reinforcement post-discharge to facilitate knowledge translation and skill acquisition. Outcomes will focus on critical self-care concepts of self-care agency, medication treatment adherence, and 30-day hospital readmissions. If proven effective, implementing this culturally informed, nursing-led transitional care model more widely could significantly impact HF outcomes and preventable hospital readmissions for Saudi HF patients.

Theoretical Structure

Definition of Concepts

Self-care agency refers to patients’ capacity to effectively carry out self-care activities necessary for adequate heart failure (HF) management. As conceptualized by Orem’s self-care deficit nursing theory guiding this study, self-care agency encompasses knowledge, motivation, and skills to perform essential HF self-care behaviors (Tanaka, 2022). An essential self-care requisite for HF patients is medication adherence, theoretically defined as correctly following complex HF medication regimens over time as providers prescribe (Zisis et al., 2021). Medication non-adherence frequently arises from poor self-care agency, precipitating acute HF exacerbations that often require hospitalization. A significant adverse outcome reflects decompensated HF necessitating repeat hospitalization within 30 days of discharge, indicating failed transitional care (Kripalani et al., 2019). This 30-day hospital readmission measure constitutes an urgent indicator of suboptimal HF care quality requiring system improvement. Enhancing patients’ self-care agency, particularly regarding medication adherence, could potentially reduce this recurrent outcome. Orem’s theoretical framework underscores the vital role of nurses in assessing and addressing HF self-care knowledge and skill deficits that limit patients’ agency for adequate self-management after hospital discharge (Butler et al., 2023). Without proper education and training, patients lack the requisite capacities to avoid instability and hospital returns. Building self-care agency enables engagement in appropriate stabilizing behaviors like adherence. Consequently, this study’s nursing educational intervention aligns with Orem’s focus on promoting self-care agency and targeting knowledge gaps to empower HF patients to meet their therapeutic needs, potentially mitigating 30-day readmissions (Ghorbanzadeh et al., 2023). Tailoring programming to Saudi patients’ unique cultural and health literacy requirements can effectively improve HF capacities for this population with poor awareness and significant barriers (Mujamammi et al., 2020).

Linkages Between Concepts

Orem’s self-care deficit nursing theory recognizes self-care agency, or patients’ knowledge, willingness, and abilities to perform key behaviors to effectively manage chronic illnesses, as fundamental to achieving optimal health outcomes. In heart failure (HF), higher self-care agency is required for adequate control through complex medication regimens and symptom monitoring (Jaarsma et al., 2021). Patients must possess knowledge of diverse HF medications, willingness to take multiple pills daily, and skills to adhere to demanding schedules for maximal therapeutic effects. When self-care agency deficits exist, patients frequently struggle to take HF medications as prescribed, exhibiting poor adherence (Liljeroos et al., 2020). They may also lack skills in additional self-care realms like restricting fluid and sodium intake, recording daily weights, and promptly responding to escalating symptoms. Execution of HF self-care behaviors encompassed under self-care agency is imperative for stability. Poor medication adherence precipitated by inadequate patient self-care agency often directly results in acute HF exacerbations mandating hospitalization (Seid et al., 2019). Non-adherence can cause fluid overload, pulmonary congestion, and blood pressure derangements if medications like diuretics or ACE inhibitors are not taken regularly (Baymot et al., 2022). Uncontrolled fluid volumes or sudden medication withdrawal also commonly trigger debilitating HF symptoms like dyspnea, fatigue, and edema, severely reducing functional status. Patients frequently require inpatient care for IV diuresis and stabilization when self-care agency deficits manifest as medication non-adherence (Seferovic et al., 2019). By failing to take medications correctly due to knowledge gaps or skill limitations, patients cannot care for themselves adequately at home. Cultivating a self-care agency through comprehensive HF education and training in medication adherence and symptom monitoring skills during hospitalization may prevent 30-day readmissions (Toukhsati et al., 2019). Patients with improved understanding, willingness, and capacities to actively participate in treatment can better execute adherence and promptly respond to deteriorations after discharge. Boosting self-care agency reduces the risk that inadequate self-care engagement precipitated by personal limitations could result in medication non-adherence, fluid overload, or unmanaged symptoms, prompting early repeat hospitalization.

Empirical Structure

Definitions

The operationalization of critical variables is vital to quantitatively assess the theoretical concepts underlying this study’s proposed nursing intervention. Four essential measures will enable the examination of the intervention’s impact on the cultivation of self-care capacities, medication regimen adherence, and 30-day hospital readmission rates. The Self-Care of Heart Failure Index (SCHFI) provides a robust gauge of patients’ self-care agency by scoring self-reported heart failure self-care maintenance behaviors, symptom management skills implemented when acute changes occur, and confidence in performing essential self-care activities (Tanaka, 2022). Its theoretical scoring range of 0-100 facilitates explicit quantification of this central concept, with higher scores indicating superior self-care engagement across domains. The Medication Specific Adherence Scale (MSAS) captures a pivotal self-care behavior in heart failure treatment via patient reports on how medications were taken as prescribed over the past month using a 0-5 scale (Zisis et al., 2021). Greater values signify better achievement of recommended adherence standards to optimize pharmacological therapies. Thirty-day hospital readmission rates, drawn from hospital discharge indexes, offer an objective population-level indicator of the intervention’s effectiveness in curbing preventable repeat admissions shortly after discharge (Kripalani et al., 2019). As a proxy for acute heart failure exacerbations, lower rates point to more robust self-care capacities and symptom control. Together, these measures enable direct testing of the theoretical proposition that comprehensive in-hospital education paired with post-discharge telephone reinforcement will improve self-care agency and medication adherence, translating to reduced 30-day readmissions. The SCHFI and MSAS provide complementary patient-centered data on knowledge application and regimen compliance, while readmission rates capture population outcomes. Limitations may include potential response biases on self-report instruments and the influence of external variables on readmissions. However, the measures exhibit psychometric solid properties and capture concepts integral to the intervention framework.

Evaluation of Operationalization

The operationalization of key concepts in this study relies on established self-report measures that have demonstrated adequacy in capturing the constructs of interest, although certain limitations exist. The Self-Care Heart Failure Index (SCHFI) provides a multi-dimensional assessment of patients’ self-care agency through quantifying adherence behaviors, self-monitoring practices, and confidence levels. Research indicates that the SCHFI exhibits good construct validity in measuring core elements that enable patients to manage their heart failure actively, supporting its selection as an empirical indicator aligned with the self-care agency concept (Tanaka, 2022). However, the scale may not fully capture the nuances of patients’ self-efficacy beliefs that strongly influence motivation and skills application (Zisis et al., 2021). The Morisky Medication Adherence Scale (MMAS) directly measures patients’ medication-taking behaviors by self-reporting lapses across situations. As medication non-adherence commonly triggers acute decompensation events, the MMAS score offers valuable data on this vital self-care domain (Butler et al., 2023). Still, reliance on patient disclosure rather than objective quantification of adherence is an inherent limitation, given biases like social desirability. Hospital discharge data offers perhaps the most accurate indicator of the critical outcome of 30-day readmissions. However, aggregate readmission data alone cannot provide context on the reasons behind acute care needs (Kripalani et al., 2019). So, while accurately delineating this proximal endpoint, supplementary data are essential to interpret and draw implications from obtained rates. In alignment with the conceptual framework, self-care capacities represent the central pathway influencing distal outcomes of hospital utilization and prognosis (Mesbahi et al., 2020). Given the extensive patient education, monitoring, regimen complexity, and lifestyle adjustments heart failure requires, the SCHFI reasonably reflects the knowledge and skill levels needed for adequate self-management and control (Aldihan et al., 2021). Despite limitations like self-report biases, the MMAS has demonstrated adequate concordance with objective adherence data sources. Thus, these measures of self-care agency and medication-taking behaviors capture proximal drivers of acute events requiring readmission reasonably well for testing study hypotheses. During interpretation, limitations regarding depth and precision will be weighed against the conceptual definitions and multi-dimensional nature of the self-care concepts. However, the selected operationalization tools largely exhibit construct validity in assessing the impacts of this tailored educational intervention approach. The translational potential of findings about measurement factors will further be considered as this protocol is refined.

Figure 1: Definitions

Horizontal Linkages

Orem’s self-care deficit theory provides the overarching conceptual framework guiding this research study. A key tenet of this theory is that self-care agency, defined as patients’ knowledge, motivation, and capabilities to perform essential self-care, enables engagement in health-promoting behaviors to meet therapeutic needs for adequate disease control. In heart failure (HF), such requisite behaviors include medication adherence, symptom monitoring, appropriate lifestyle modifications, and prompt care-seeking when symptoms worsen. Multiple empirical studies have provided evidence supporting the theoretical relationships posited by Orem between greater self-care agency through educational interventions and improved performance of these self-management behaviors, including more consistent medication-taking (Ad et al., 2016; Attaallah et al., 2021). Notably, significant negative correlations exist in the literature between patients’ medication adherence levels and the likelihood of 30-day hospital readmissions. This aligns with the study’s conceptual framework in reinforcing medication adherence as a pivotal mediating factor in the causal pathway between enhanced self-care agency and reduced hospitalizations. As equipped with better self-care skills through this tailored educational intervention, patients may be less likely to improperly miss HF medications or inadequately recognize and respond to worsening symptoms, preventing acute decompensation events requiring hospitalization. Consistently across settings, poorer medication adherence is associated with a higher risk of repeat HF hospitalizations (Jarab et al., 2023; Knafl & Riegel, 2014). Quantitatively assessing medication adherence provides an opportunity to evaluate its role as an explanatory mechanism linking the exposure variable of patients’ post-intervention self-care agency and the outcome variable of 30-day readmission rates. A mixed-model analysis is therefore essential to test the hypothesized causal linkages within Orem’s theoretical model, from the enhanced self-care agency through improved medication adherence leading to a significantly reduced likelihood of early hospital returns. Elucidating these expected horizontal linkages helps clarify the underlying mechanisms by which the customized Saudi HF educational regimen may reduce preventable 30-day readmissions.

Vertical Linkages

The vertical linkages in the theoretical subtraction diagram connect the abstract concepts from theory to the concrete empirical indicators used to measure the concepts operationally. Several key vertical linkages help ensure consistency between conceptual definitions and selected measurement tools. The concept of self-care agency, representing patients’ capacities to perform essential HF self-management, aligns with the Self-Care of Heart Failure Index (SCHFI) that quantifies self-care maintenance, management, and confidence. The SCHFI assessment of knowledge, skills, and willingness maps directly to the theoretical definition of self-care agency. Medication adherence, defined as correctly following complex HF treatment regimens, matches the operationalization of the Medical Outcomes Study Specific Adherence Scale (MSAS) that measures the extent of adherence behaviors. MSAS adherence reports correlate with objective pharmacy refill rates and blood therapeutic levels, confirming measurement validity. Additionally, the concept of 30-day hospital readmission, a critical consequence of inadequate self-care capacities leading to acute decompensation events, aligns with tracking readmission rates using hospital indices. Administrative data verifies early rehospitalizations due to exacerbations of the HF condition. The identified vertical linkages through transformational statements connect the theoretical and operational systems, helping substantiate that selected empirical indicators accurately and consistently reflect intended concepts. By mapping concepts to indicators, the subtraction framework establishes theoretical consistency with measurement tools like the SCHFI, MSAS, and hospital readmission indices. The linkage of conceptual definitions to empirical operationalization ensures that study variables derive from and remain grounded in the guiding theory. Vertical integration is vital for confirming research designs measure what they theoretically purport to measure. As such, thoughtful vertical linkages reinforce operationalization validity and aid hypothesis testing to advance nursing science. The outlined vertical relationships align Orem’s self-care deficit theory with instruments quantifying self-care agency, behaviors, and outcomes in Saudi HF patients.

Figure 2: Conceptual Links

Theoretical and Empirical Consistency

The overall vertical alignment between the operational definitions and measurement tools selected with the theoretical concepts and their definitions within Orem’s self-care deficit model is essential in guiding the intervention for this research. The instruments measuring key variables of self-care agency, medication adherence, symptom monitoring, lifestyle changes, and 30-day readmissions reflect the concepts delineated in the model. For example, the Self-Care of Heart Failure Index (SCHFI) reasonably encapsulates the knowledge and skills dimensions comprising self-care agency (Evangelista et al., 2013). However, it may be limited in fully capturing the motivation aspect. Similarly, the measurement of medication adherence via the Medication Specific Adherence Scale (MSAS) correlates well with pharmacy refill and biochemical validation data, relying considerably on the accuracy of patient self-reports. Additionally, identified relationships of influence and predicted causality between variables horizontally across the model are widely affirmed through empirical evidence. Numerous studies confirm associations between improved self-care capacities, better medication adherence, symptom control, lifestyle modifications, and lower hospitalizations (Baryakova et al., 2023; Baymot et al., 2022; Seid et al., 2019). However, the instruments selected cannot incorporate all facets of each concept and their dynamic interactions. For instance, while influenced significantly by care quality and system-level factors, 30-day readmission rates frequently stem directly from patients’ inability to avoid acute decompensation events due to poor self-care. There remains room for enhancing concordance between measurement tools and the multilayered theoretical concepts underlying self-care agency. Despite this, the chosen operationalization methods and empirical indicators demonstrate adequate consistency with Orem’s conceptual delineations of key elements related to the study’s focus. Residual limitations regarding instruments fully capturing theorized mechanisms interlinking concepts will be highlighted.

Research Questions

1. Does implementing a tailored, culturally-informed educational intervention focused on teaching self-care skills and principles improve self-care agency in hospitalized Saudi HF patients from admission to 30 days post-discharge compared to usual care?
2. Does enhanced self-care agency from admission to 30 days post-discharge increase medication regimen adherence at 30 days in Saudi HF patients receiving the educational intervention compared to usual care?
3. Is the relationship between increased self-care agency and reduced 30-day hospital readmission rates mediated by improvements in medication adherence for Saudi HF patients receiving the tailored educational intervention?
4. Do Saudi HF patients experiencing supportive nursing educational intervention exhibit lower 30-day hospital readmission rates than patients receiving usual care?
5. What barriers and facilitators to intervention implementation and sustainability are identified amongst nurses and Saudi HF patients in the clinical setting?

References

Ad, G., M, R., V, Z., K, A., & N, N. (2016). Limitations of self-care behaviour in heart failure patients-a qualitative research with approach Orems theory. Biomedical Research, 0(0), 437–442. https://www.alliedacademies.org/abstract/limitations-of-selfcare-behaviour-in-heart-failure-patientsa-qualitative-research-with-approach-orems-theory-6169.html

Adam, T., Al Sharif, A. I., Alamri, T. S. M., Al-Nashri, R. A. O., Alluwimi, A. I. M., Samkri, A. Y., Alharthi, M. A., Moafa, A. Y., Alsaadi, N. A., Alraimi, A. M. S., & Alquzi, R. H. M. (2023). The State of Cardiac Rehabilitation in Saudi Arabia: Barriers, Facilitators, and Policy Implications. Cureus, 15(11), e48279. https://doi.org/10.7759/cureus.48279

Aldihan, D. A., Alghafees, M. A., Alharbi, R. O., Allahidan, R. S., AlOmar, R. H., Alenazi, A. F., & Suliman, I. F. (2021). Readmission Rates of Heart Failure and Their Associated Risk Factors in a Tertiary Academic Medical City in Riyadh, Saudi Arabia. Journal of Nature and Science of Medicine, 4(1), 64. https://doi.org/10.4103/JNSM.JNSM_57_20

Aljabri, A. (2021). An inpatient multidisciplinary educational approach to reduce 30-day heart failure readmissions. Saudi Pharmaceutical Journal, 29(4), 337–342. https://doi.org/10.1016/j.jsps.2021.03.008

Alshibani, M., Alshehri, S., Alyazidi, W., Alnomani, A., Almatruk, Z., & Almeleebia, T. (2020). The Impact of Discharged Loop Diuretic Dose to Home Dose on Hospital Readmissions in Patients with Acute Decompensated Heart Failure: A Retrospective Cohort Study. The Heart Surgery Forum, 23(4), Article 4. https://doi.org/10.1532/hsf.3029

Attaallah, S. A., Peters, R. M., Benkert, R., Yarandi, H., Oliver-McNeil, S., & Hopp, F. (2021). Developing a Middle-Range Theory of Heart Failure Self-Care. Nursing Science Quarterly, 34(2), 168–177. https://doi.org/10.1177/0894318420987164

Baryakova, T. H., Pogostin, B. H., Langer, R., & McHugh, K. J. (2023). Overcoming barriers to patient adherence: The case for developing innovative drug delivery systems. Nature Reviews Drug Discovery, 22(5), Article 5. https://doi.org/10.1038/s41573-023-00670-0

Baymot, A., Gela, D., & Bedada, T. (2022). Adherence to self-care recommendations and associated factors among adult heart failure patients in public hospitals, Addis Ababa, Ethiopia, 2021: Cross-sectional study. BMC Cardiovascular Disorders, 22(1), 275. https://doi.org/10.1186/s12872-022-02717-3

Butler, J., Petrie, M. C., Bains, M., Bawtinheimer, T., Code, J., Levitch, T., Malvolti, E., Monteleone, P., Stevens, P., Vafeiadou, J., & Lam, C. S. P. (2023). Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post–hospital discharge period. Research Involvement and Engagement, 9(1), 23. https://doi.org/10.1186/s40900-023-00412-x

Evangelista, L., Lee, J.-A., Moore, A., Motie, M., Ghasemzadeh, H., Sarrafzadeh, M., & Mangione, C. (2013). Examining the Effects of Remote Monitoring Systems on Activation, Self-care, and Quality of Life in Older Patients With Chronic Heart Failure. The Journal of Cardiovascular Nursing, 30. https://doi.org/10.1097/JCN.0000000000000110

Ghorbanzadeh, M., Khosravirad, Z., Rostamzadeh, M., Azizi, S., Khodashenas, M., Shahraki, B. K., & Ghasemi, F. (2023). The Efficacy of Self-care Behaviors, Educational Interventions, and Follow-up Strategies on Hospital Readmission and Mortality Rates in Patients with Heart Failure: Self-care Behaviors in Heart Failure Patients: Self-care Behaviors in Heart Failure Patients. Galen Medical Journal, 12, e3116–e3116. https://doi.org/10.31661/gmj.v12i.3116

Jaarsma, T., Hill, L., Bayes‐Genis, A., La Rocca, H. B., Castiello, T., Čelutkienė, J., Marques‐Sule, E., Plymen, C. M., Piper, S. E., Riegel, B., Rutten, F. H., Ben Gal, T., Bauersachs, J., Coats, A. J. S., Chioncel, O., Lopatin, Y., Lund, L. H., Lainscak, M., Moura, B., … Strömberg, A. (2021). Self‐care of heart failure patients: Practical management recommendations from the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 23(1), 157–174. https://doi.org/10.1002/ejhf.2008

Jarab, A. S., Al-Qerem, W. A., Hamam, H. W., Alzoubi, K. H., Abu Heshmeh, S. R., Mukattash, T. L., & Alefishat, E. (2023). Medication Adherence and Its Associated Factors Among Outpatients with Heart Failure. Patient Preference and Adherence, 17, 1209–1220. https://doi.org/10.2147/PPA.S410371

Knafl, G. J., & Riegel, B. (2014). What puts heart failure patients at risk for poor medication adherence? Patient Preference and Adherence, 8, 1007–1018. https://doi.org/10.2147/PPA.S64593

Kripalani, S., Chen, G., Ciampa, P., Theobald, C., Cao, A., McBride, M., Dittus, R. S., & Speroff, T. (2019). A Transition Care Coordinator Model Reduces Hospital Readmissions and Costs. Contemporary Clinical Trials, 81, 55–61. https://doi.org/10.1016/j.cct.2019.04.014

Liljeroos, M., Kato, N. P., van der Wal, M. H. L., Brons, M., Luttik, M. L., van Veldhuisen, D. J., Strömberg, A., & Jaarsma, T. (2020). Trajectory of self-care behaviour in patients with heart failure: The impact on clinical outcomes and influencing factors. European Journal of Cardiovascular Nursing, 19(5), 421–432. https://doi.org/10.1177/1474515120902317

Mesbahi, H., Kermansaravi, F., & Kiyani, F. (2020). The Effect of Teach-Back Training on Self-Care and Readmission of Patients with Heart Failure. Medical – Surgical Nursing Journal, 9(3), Article 3. https://doi.org/10.5812/msnj.111465

Mujamammi, A. H., Alluhaymid, Y. M., Alshibani, M. G., Alotaibi, F. Y., Alzahrani, K. M., Alotaibi, A. B., Almasabi, A. A., & Sabi, E. M. (2020). Awareness of cardiovascular disease associated risk factors among Saudis in Riyadh City. Journal of Family Medicine and Primary Care, 9(6), 3100. https://doi.org/10.4103/jfmpc.jfmpc_458_20

Negarandeh, R., Aghajanloo, A., & Seylani, K. (2020). Barriers to Self-care Among Patients with Heart Failure: A Qualitative Study. Journal of Caring Sciences, 10(4), 196–204. https://doi.org/10.34172/jcs.2020.026

Seferovic, P., Ponikowski, P., Anker, S., Bauersachs, J., Chioncel, O., Cleland, J., de Boer, R., Drexel, H., Ben-Gal, T., Hill, L., Jaarsma, T., Jankowska, E., Anker, M., Lainscak, M., Lewis, B., McDonagh, T., Metra, M., Milicic, D., Mullens, W., & Coats, A. (2019). Clinical practice update on heart failure 2019: Pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of The Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 21. https://doi.org/10.1002/ejhf.1531

Seid, M. A., Abdela, O. A., & Zeleke, E. G. (2019). Adherence to self-care recommendations and associated factors among adult heart failure patients. From the patients’ point of view. PLoS ONE, 14(2), e0211768. https://doi.org/10.1371/journal.pone.0211768

Tanaka, M. (2022). Orem’s nursing self-care deficit theory: A theoretical analysis focusing on its philosophical and sociological foundation. Nursing Forum, 57(3), 480–485. https://doi.org/10.1111/nuf.12696

Toukhsati, S., Jaarsma, T., Babu, A., Driscoll, A., & Hare, D. (2019). Self-Care Interventions That Reduce Hospital Readmissions in Patients With Heart Failure; Towards the Identification of Change Agents. Clinical Medicine Insights. Cardiology, 13, 1179546819856855. https://doi.org/10.1177/1179546819856855

Zisis, G., Carrington, M. J., Oldenburg, B., Whitmore, K., Lay, M., Huynh, Q., Neil, C., Ball, J., & Marwick, T. H. (2021). An m-Health intervention to improve education, self-management, and outcomes in patients admitted for acute decompensated heart failure: Barriers to effective implementation. European Heart Journal – Digital Health, 2(4), 649–657. https://doi.org/10.1093/ehjdh/ztab085