A pilot randomized clinical trial of a teamwork intervention for heart failure care dyads
Introduction
The prevalence of heart failure (HF) in the United States is increasing with approximately 6.2 million Americans currently living with HF.1 These individuals are recommended to follow a complex self-management regimen and rarely assume self-management alone.2 Moreover, the trajectory of illness is highly variable and most persons with HF remain in the community through the advanced stages of their disease while receiving assistance from their family caregivers.3 The central role of family caregivers in the management of HF has been well documented in the literature.4,5 However, caregivers of persons with HF report poor health-related quality of life, significant stress, deferred self-care, and depression.6,7 The evidence about self-management complexity and family caregivers’ poor health outcomes highlights the need to improve outcomes for both members of the dyad (i.e., the person living with HF and their family caregiver).
Dyadic illness management is a novel behavioral paradigm that focuses on partnerships between individuals with chronic illness and their family caregivers to manage health and illness.8 In contrast to other health and illness management theories, dyadic illness management focuses on the interdependence in how a person living with a chronic illness and their family caregiver appraise the illness and engage in health promoting behaviors to enhance their health as a dyad.8 In the context of HF management, dyadic illness management shifts the focus from the conventional paradigm centered around patient behaviors or caregiver contributions, to a dyadic orientation to promote sustained HF management that can result in substantial improvements in the health and well-being of the person with HF and their family caregiver.8,9 Dyadic HF management is a rapidly emerging area of research that has gained recent attention in the self-management literature. Researchers used qualitative and quantitative methodologies to identify different dyadic care types that exemplify how persons with HF and their family caregivers – the dyad – work as a unit to manage HF and improve their quality of life.10,11
Dyadic illness management is characterized by illness appraisal and management behaviors that both members of a dyad engage in as a unit to influence dyadic health.8 Research suggests that greater congruence in the appraisal of care values and preferences as well as shared decision making can lead to better dyadic management behaviors, balancing the needs of both members.12., 13., 14., 15. Moreover, how dyads communicate14,16,17 and relate to one another18., 19., 20., 21. is posited to contribute to greater dyadic appraisal and more collaborative management behaviors, having lasting effects on the health of patients and their caregivers. Thus, interpersonal communication and relationship quality are modifiable factors that can be a target for intervention to improve dyadic management behaviors, and subsequently dyadic health.
Previous research has long established the role of confidence, or self-efficacy in HF self-management.22 More recently, Lyons and colleagues23 examined the concept of dyadic confidence and its influence on engagement in HF management for patients and their spousal family caregivers. Dyadic confidence was operationalized in three ways, by calculating the average score of confidence, the gap in confidence, and the direction of the gap within each dyad. A greater dyadic average confidence was associated with better self-management for the person with HF. Moreover, a larger gap in confidence scores between patients and their spouses, indicating incongruence in confidence, was associated with less spousal engagement in HF management. Given the lack of a gold-standard measure of dyadic HF management, the engagement of both members of a dyad in HF management can be considered an indicator of dyadic HF management. Therefore, dyadic confidence is an influential contributor to dyadic HF management.23 It is important to focus on improving confidence, or self-efficacy for both members of the dyad while decreasing the gap between self-efficacy levels for the person with HF and their family caregiver.
Based on a recent systematic review, few dyadic HF interventions had sustained effects on patient and caregiver outcomes.24 Additionally, few investigators used electronic health (eHealth) technology to deliver their interventions.24 Dyadic HF management can be enhanced through eHealth interventions, which are emerging as an acceptable and efficient alternative to in-person, clinician- or paraprofessional-delivered interventions. A preponderance of eHealth interventions to improve HF management has solely focused on the patient, missing the opportunity to engage family caregivers.25., 26., 27. Yet, there is promising evidence to support the feasibility of eHealth dyadic interventions and their initial efficacy on dyadic illness management, and patient and caregiver outcomes, such as self-efficacy and quality of life.28
The evidence base on efficacious interventions to improve dyadic HF management is relatively nascent and, given the paucity of interventional research, rigorous clinical trials are needed to support dyads living with HF. To address the current need for interventional research focused on dyadic HF management, we conducted a pilot study of a dyadic eHealth intervention, eSMART-HF (electronic Shared MAnagement and Relationship Training for Heart Failure). eSMART-HF focused on enhancing teamwork skills for dyadic HF management and encouraged persons with HF and family caregivers to explore areas for improved communication and mutual support.
The purpose of this article is two-fold. First, we will report the feasibility and acceptability of administering two eHealth experimental conditions (eSMART-HF vs. screen-based education) in a dyadic context. Secondly, we provide preliminary data on the effects of eSMART-HF compared with a screen-based educational condition on measures of communication, decision making, relationship quality, self-efficacy, and quality of life among dyads of persons with HF and their family caregivers. The eSMART-HF condition was designed to focus on dyadic illness management by promoting goal setting, interpersonal communication, and relationship quality within each dyad. Therefore, we posited that participants exposed to eSMART-HF will demonstrate better communication, decision making, relationship quality, self-efficacy, and quality of life, compared to those randomly assigned to screen-based education.
Section snippets
Design
This is a two-arm randomized, pilot clinical trial of eSMART-HF compared to an attention control condition (screen-based education [SBE]). A nonprobability sample of patient-family caregiver dyads was recruited from a large academic medical center and data were collected at baseline and one-week post-intervention. All study procedures were approved by the University Hospitals Institutional Review Board.
Participants
Patients were eligible if they: (a) were diagnosed with HF, (b) were hospitalized for a HF
Participants
Table 1 presents the demographic and clinical characteristics of the participants. Most patients were male (64.3%), non-employed (75%), and married or in a relationship (60.7%). Caregivers were younger than patients, mostly female (78.6%), and were the patient's spouse or partner (60.7%). The racial distribution of our sample is different from other samples reported in the HF self-management literature, with most patients (67.9%) and caregivers (71.4%) self-identifying as Blacks. The
Discussion
In this pilot study, we tested the feasibility, acceptability, and preliminary efficacy of an eHealth teamwork intervention for dyadic HF management developed based on social cognitive theory and teamwork principles derived from the organizational behavior literature. The goal of the intervention was to promote collaboration among adults with HF and their family caregivers. Our findings provide preliminary support for the feasibility and acceptability of the intervention, and demonstrate its
Funding Sources
The study was funded by the Council for the Advancement of Nursing Science and the Virginia Stone Funds of the American Nurses Foundation. Dr. Irani's postdoctoral training was supported by the National Institute of Nursing Research of the National Institutes of Health (T32NR015433: Multiple Chronic Conditions, Interdisciplinary Nurse Scientist Training; Principal Investigator, Dr. Shirley M. Moore).
Declaration of Competing Interest
None.
Acknowledgments
We thank Mrs. Vaani Nanavaty for recruiting participants and collecting data.
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