INTRODUCTION

Heart failure (HF) is a chronic disease and a growing public health problem. According to the Portuguese Society of Cardiology, the prevalence of HF in Portugal is estimated around 400,000 individuals. Its incidence increases with age, constituting the first cause of hospitalization after 65 years in industrialized countries. Despite advances in medicine, clients with HF maintain high rates of mortality and rehospitalization, which are associated with high financial costs for the National Health Service¹. These data shows a lack of organization of resources in the assistance of people with HF in Portugal at the various levels of care and follow-up, making it urgent to prioritize this disease in health policies.

Nurses play an active role in preventing cardiovascular disease, as evidence demonstrates that multidisciplinary programs coordinated by nurses are more effective than usual care in reducing cardiovascular risk ². Nurses, in addition to constituting the largest professional group in healthcare, have teaching and communication skills that enhance clients' adherence behaviors ³⁾⁽⁴.

Likewise, the Portuguese Society of Cardiology recognizes, in its recommendations, the role of the specialist nurse in rehabilitation nursing (RN) as a fundamental element of the cardiac rehabilitation (CR) teams, based on the core of specific competences of the same specialty ⁵. CR programs are intended to respond to the improvement of the health potential of people with heart problems, and are constituted by multidisciplinary teams with complementary support functions that include assessment of cardiovascular risk; health education; early mobilization and physical exercise training ⁶⁾⁽⁷. Although in the literature it is divided into three phases - inpatient, outpatient and long-term intervention (designated, respectively, as phases 1, 2 and 3), CR must constitute a continuous process throughout the life cycle ^{4)( 8)}.

Considering the evidence described in the literature and national and international recommendations, it is crucial to create strategies that allow self-care and self-management of HF, including CR ^{4)(7)(9)(10)(11) (12)(13}.

METHODOLOGY

Original study based on the quantitative paradigm and, considering the follow-up, of the prospective longitudinal type. Based on manipulation, this is a quasi-experimental study with a single-group before-after design. The option for a quasi-experimental study is related to the existence of sufficient evidence of the benefits of the interventions under study (namely CR programs and nursing follow-up in the person with HF), so establishing a control group would constitute a ethical dilemma.

The guide for quasi-experimental studies (Transparent Reporting of Evaluations with Nonrandomized Designs: TREND) was used as a reference in the planning and execution of this research ¹⁶.

A non-probabilistic convenience sample consisting of 110 participants included in the REPIC program was established. Inclusion criteria were established: patients admitted to the service with HF diagnosis and acceptance to participate in the study. The following exclusion criteria were established: clients undergoing cardiac surgery, heart transplantation or percutaneous valve implantation, as it is intended at this stage to include clients with HF as a clinical diagnosis.

The REPIC program was initiated during hospitalization and included education, physical exercise training and follow-up after discharge. The follow-up was carried out by telephone contact at the end of 1 month, 6 months and 1 year after discharge, with data collection carried out using forms designed for this purpose (see figure 1).

Figure 1 Design of the study carried out 

The independent variable is the REPIC program (RN intervention that includes health education, exercise training during hospitalization and follow-up after discharge). Sociodemographic characterization variables include age, sex and cardiovascular risk factors. The variables considered as dependent were operationally defined as follows:

The hypotheses established with this research include:

To carry out this research, all ethical procedures were ensured, namely obtaining informed consent from the participants, and approval by the institutional ethics committee (Ref. 526/2012).

Inferential and descriptive statistics were used for data analysis to characterize the variables under study. Student's t test for paired samples was used to compare means and assess differences, before and 1 year after the REPIC program. The data obtained were stored and analyzed using the SPSS software (version 27) and the significance level adopted was 5% (p value < 0.05).

RESULTS

The sociodemographic characterization of the sample reveals that most participants are male (66%) and 34% are female. With regard to age, the range varies between a minimum age of 30 and a maximum of 89, with an average of 64.3 years-old and a standard deviation of 14.4 (figure 2).

Figure 2 Sample characterization: age 

With regard to cardiovascular risk factors, there is a predominance of arterial hypertension and sedentary lifestyle, corresponding to approximately 74% of the sample, followed by diabetes and dyslipidemia (present in about 50% of the participants) and finally smoking , present in 21% of the participants (figure 3).

Figure 3 Sample characterization: cardiovascular risk factors 

The evaluation of the impact of the REPIC program regarding the level of knowledge about HF was operationally defined by the responses resulting from the application of the European Heart Failure Self-care Behavior Scale ¹⁷. For this purpose, the means of responses obtained between the assessment carried out before the REPIC program and the assessment carried out 1 year later were compared, using Student's t test for paired samples (Table 1).

Regarding the assessment of the impact of the program on the perception of quality of life, this was operationally defined by the responses obtained by applying the EuroQOL Scale. Likewise, the averages of the answers obtained between the evaluation prior to the implementation of the REPIC program and the evaluation carried out 1 year later were compared (Table 2). As for the perception of health status, this was operationally defined by the visual analogue scale included in the EuroQOL Scale, with 0 being the “worst health status” and 100 the “best health status.

Finally, table 3 represents the results obtained relative to the average duration of daily physical exercise (in minutes). It was verified that there are statistically significant differences between the previous moment of implementation of the REPIC program (M=17.04; SD=22.67) and at the end of one year (M=33.32; SD=20.99), these results being also confirmed by the t test for paired samples t (109)=6.03; p=0.01.

DISCUSSION

The analysis of the results allows us to conclude that there was an improvement in the level of knowledge about the disease in the study participants in all dimensions of the scale after the REPIC program, with a statistically significant result (p=0.01).

The results of this study demonstrated that there is a positive impact on the level of knowledge about the disease, an improvement in the perception of quality of life and that there are differences in the average time spent performing physical exercise with the REPIC program. The improvement in the perception of quality of life in people with HF after the REPIC program, were revealed with statistical significance in the dimensions of mobility (p=0.01); personal care (p=0.01); usual activities (p=0.01) and general level of health (p=0.01). Finally, the analysis of the results led to the conclusion that there are differences in the perception of the health status evaluated before the implementation of the REPIC program (M=50.9; SD=17.36) and 1 after the same intervention program (M=69, 5;SD=18.8), these data being also confirmed by Student's t test for paired samples t(109)=7.67; p=0.01.

The state of the art corroborates the results of this research, as nurses, through the health education practices, enhances the understanding of the disease, increases self-management behaviors and reinforces the surveillance of the signs and symptoms of HF decompensation. In fact, recommendations of the European Society of Cardiology also associates nurse education on self-management of HF with a lower risk of hospital readmissions and mortality reduction⁹. In line with the results of our research, the results of a study revealed that nursing education on self-management significantly improved disease self-management behaviors in people with HF. This difference was statistically significant (β = 4.15, p < 0.05) and increased with each education session ¹⁹. Hospitalization constitutes a period of excellence for the beginning of the education program on self-management behaviors, since the person and the caregiver are more receptive and available to assimilate the contents and daily contact with RN specialists is facilitated. The REPIC program includes a systematic and standardized education program during hospitalization and educational reinforcements provided at clinical discharge, supported by flyers. Such strategies seem to improve understanding about the disease, its treatment and, consequently, adherence to the therapeutic regimen, with an improvement in quality of life. Another investigation concluded that a nursing intervention and follow-up program implemented in people with HF improved self-management behaviors and quality of life, being also associated with a lower number of hospitalizations ²¹. However, in contrast to the results of our study, a meta-analysis indicated that nursing education on self-management of the disease is not associated with improvements in quality of life or knowledge about HF ²². Such contradictory results may be due to the fact that quality of life is not a reliable result measure in short-term interventions. On the other hand, the impact of nursing education on disease self-management is intrinsically dependent on the duration and frequency of the educational process, which are enhanced by periodic follow-ups over time.

Regarding Nursing follow-up after discharge, the results of one study are in line with the results of our research. This randomized study found greater adherence to pharmacological and non-pharmacological behaviors in the Intervention Group that was subject to Nursing education and telephone monitoring (p<0.001). The lowest rate of readmissions and mortality in the Intervention Group after 90 days was another of the results obtained ²³. Such conclusions reinforce the importance of telephone follow-up as an alternative strategy associated with multiple benefits (greater adherence to therapy, reduction in readmissions and mortality). In addition, it ensures the monitoring of some people with HF, considering certain factors such as availability to travel to hospital units, clinical status/comorbidities and geographical distance.

In regard to physical exercise training in people with HF, there is consistent literature evidence that corroborates the results and demonstrates that CR programs and physical exercise training improves functional capacity and quality of life. Clinical trials and meta-analyses performed in people with HF with reduced ejection fraction demonstrates that CR reduces hospital readmissions for HF, although uncertainty persists about its effects on mortality ⁹. The practice of regular physical exercise in people with HF is associated with improved functional capacity and constitutes a recommendation Level of Evidence IA¹⁵. A meta-analysis refers beneficial effects of exercise-based CR on HF, improvement in functional capacity and quality of life, as well as decreased hospitalization and mortality ²⁴. Likewise, the institution of protocols with physical exercise that include walking and upper limb muscle strength training improves the performance of daily life activities, gait and functional capacity in people with HF ¹¹. Regarding the REPIC program, exercise training was performed during hospitalization, which allowed the assessment of individual functional capacity, facilitated the initiation of physical exercise in a controlled environment and the management of symptoms and potential complications before hospital discharge. Thus, the conclusions of our research are in line with the results of the INCARD study, by confirming the benefits of in-hospital rehabilitation, namely in the improvement in the left ventricular ejection fraction and increase in the maximum volume of oxygen, which corroborates the idea that training with physical exercise has a positive impact on these people and should be performed regardless of the HF etiology ¹³. Likewise, the results of the randomized ERIC-HF study also prove that there are statistically significant differences between the group that underwent an exercise training intervention during hospitalization and the control group. The ERIC-HF protocol, like the REPIC program, demonstrated safety and efficacy during its implementation, with no adverse effects occurring. In addition, the ERIC-HF study reveals an increase in functional capacity (assessed by the 6-minute walk test and activities of daily living performance). The conclusions of this study revealed statistically significant differences of 54.2 meters for the training group (p=0.026) in the 6-minute walk test and in the performance of activities of daily living (p=0.003), but not in the level of dependence , evaluated using the Barthel index (p=0.072) ²⁵.

Although CR programs have demonstrated many clinical benefits, participation rates of clients with HF range from 14% to 43% worldwide and are also associated with high dropout rates ²⁶. Likewise, adherence to physical exercise in people with HF is a challenge, despite its benefits in functional capacity of people with HF as previously mentioned ^{11)(13)(15)(24)(25}. Based on REPIC program results, there was an increase in the average duration of time spent performing physical exercise. Thus, we can infer that this increase was enhanced by regular telephone contacts, which allowed motivating participants to practice and reinforcing the importance and benefits of physical exercise. That said, the RN, holds specific skills in the area of readaptation, education and physical exercise training, and works as a facilitating agent in the self-care adherence and self-management behaviors, as well as an promoting agent to regular exercise practice.

CONCLUSION

The present study revealed the positive impact of the REPIC program on the level of knowledge about the disease, on the perception of quality of life and on the average time spent performing physical exercise. Thus, this RN intervention program made it possible to reinforce the educational process, enhance self-management behaviors, improve quality of life and increase the average duration of regular physical exercise.

Despite the frankly positive results, the findings must be interpreted with caution due to some inherent limitations. The time period required to carry out the study was influenced by the need to ensure the planned chronological follow-up of people with HF, and corresponded to a total of six years, in order to reach the defined sample (n=100). This is due to numerous factors, including the study's exclusion criteria; the occupancy rate of the services where the study was carried out, as well as the high number of deaths that occurred during the period in which the study was carried out (n=46). Likewise, due to a shortage of nursing human resources, the CR program was suspended for a period of 6 months, which conditioned data collection and continuity of the RN intervention program. Finally, each follow-up telephone call could reach an average duration of 40 minutes, so carrying out this study also implied a lot of personal availability and motivation.

As possible biases, it should be noted that telephone contact, as a form of non face-to-face monitoring, limited the assessment and monitoring of certain parameters, such as weight, blood pressure or functional capacity. Likewise, data provided by third parties, namely caregivers (n=17), may have somehow conditioned the results obtained. In addition, the assessment of the variables under study was based on the self-report method, which is prone to estimation error and recall bias.

Finally, we highlight the need to guarantee the continuity of care at the level of primary health care, since, to date, there is no HF nursing consultation at the hospital unit where the study was carried out, due to a lack of nursing human resources. In summary, the results of the REPIC program, as a RN intervention program, provide valuable subsidies for the replication of this program in other contexts, services or institutions.