Online braz j nurs

Impact of nursing systematic education on disease knowledge and self-care at a heart failure clinic in Brazil: prospective an interventional study

 Impacto da educação sistemática de enfermagem no conhecimento da doença e autocuidado em uma clínica de insuficiência cardíaca no Brasil: um estudo experimental prospectivo

 Eneida Rejane Rabelo 1,2, Graziella Badin Aliti 2, Fernanda Bandeira Domingues 2, Karen Brasil Ruschel 2, Anelise Oliveira Brun 2, Solange Braun Gonzalez 2. 

1 Hospital de Clínicas de Porto Alegre – Serviço de Cardiologia; 2 Escola de Enfermagem da Universidade Federal do Rio Grande do Sul.


ABSTRACT. The aim of this prospective and experimental study was to evaluate the impact of nursing systematic education on disease knowledge and self-care at a Heart Failure Clinic in Brazil. Prior to the nurse’s appointment, all patients answered a structured questionnaire concerning the knowledge of the disease and self-care. After 4 appointments, the same patients answered the same questionnaire. This present study suggests that systematic education with nurses increase the knowledge about the disease and self-care. This approach together with others strategies could decrease decompensation episodes and consequently improve quality of life for heart failure patients. 

Keywords: congestive heart failure, nursing, patient education, knowledge, self care.  

RESUMO. O objetivo deste estudo experimental prospectivo foi de avaliar o impacto da educação sistemática de enfermagem sobre o conhecimento da doença e autocuidado em uma clínica de insuficiência cardíaca no Brasil. Antes da consulta de enfermagem, todos os pacientes responderam a um questionário estruturado relativo ao conhecimento da doença e autocuidado. Após quatro consultas, os pacientes responderam novamente o questionário. O presente estudo sugere que a educação sistemática de enfermagem aumenta o conhecimento sobre a doença e autocuidado. Esta abordagem, juntamente com outras estratégias, poderia diminuir episódios de descompensação e, conseqüentemente, melhorar a qualidade de vida dos portadores de insuficiência cardíaca.

Palavras chave: insuficiência cardíaca congestiva, enfermagem, educação, conhecimento, autocuidado.



Among cardiovascular diseases, congestive heart failure (CHF) is one of the most challenging disorders to the health team due to multiple etiologies, its high incidence and complex management strategies required. A main goal of the treatment of CHF consists in reaching and maintaining clinical stability of patients. Furthermore, assessment, follow-up and prevention of precipitant factors of decompensation are important objectives for the management of these patients (1-2).

Prognosis of patients with CHF depends not only on pharmacological aspects of therapy, but also on additional non-pharmacological approaches. A continuous program and systematic education about the disease, regular use of medication, restriction of salt and fluids, regular physical activity, weight control and lifestyle changes are essential. However, the ability to perform these controls depends importantly on the patients’ knowledge and skills to keep an adequate, compliant behavior (3-5) All these actions are called self-care, which have been defined as the cognitive active process undertaken by patients to maintain or manage both disease and illness (4).

In the present study, considering that clinical stability of patients with CHF requires efforts from a multidisciplinary team, and that nurses are an essential part of the process of education, maintenance and management of self-care, we have assessed the impact of a nurse systematic and educational interventional program on the knowledge about the disease and self-care in patients followed at a heart failure clinic.

In the context of CHF management many studies have demonstrated that orientations about the disease and self-care are poorly retained by patients, in average (6-7). For example, an American study lead with 123 patients to investigate what the patients know about CHF and the treatment, it demonstrated specifically that he was unsatisfactory the cares in relation to medications, the monitorization of the weight, and to the knowledge of the disease (3).

After the publication of the first randomized clinical trial which demonstrated benefits in the reduction of costs and the number of hospitalizations, besides the improvement in the quality of life of patients followed by a multidisciplinary team, other studies has confirmed that strategies that involve education are vital in CHF treatment (2, 6, 8). The magnitude of Brazilian data indicate that epidemiologic profile about CHF is similar that of developed countries.

The inexistence of data in Brazil regarding to the knowledge of the patients on CHF and self-care, as well as on the impact of strategies of education supplied by nurses remain unknown. 


Prospective interventional study. In this study patients from the Heart Failure Clinic from a University Hospital were included from 2002 until 2005. It has been conducted including all patients who, after their first medical assessment, had scheduled a first appointment with the nursing team. Just prior the nurse’s appointment patients answered a structured questionnaire including questions concerning knowledge of the disease and self-care related to heart failure. These questions were based on recommendations from the Cardiovascular Nursing Council of the American Heart Association, published in 2000 (1). The questionnaire takes approximately 15 min to be completed. In average, one and a half year later, period during which, patients had 4 nurse’s appointments, patients were asked to repeat the same questionnaire. Study endpoints include improvement in understanding of the disease and the importance of self-care as related to its non-pharmacological management which had been guided and reinforced in every appointment. The present study (number 98-140), reviewed and approved by the Human Research Committee from our institution and informed written consent was obtained from all patients before enrollment.

Statistics analysis

 Continuous variables are expressed as mean ± standard error for these with normal distribution. Categorical variables are expressed as percent. Qui-square test of McNemar was used to compare the baseline and final questionnaires. Qui-square of Pearson was used to verify the association among variables. A value of P<0.05 was considered significant. 


In this study, 60 patients aged 57 ± 13 years, 58% male were included. On Table 1 clinical characteristics the at first appointment and following 4 assessment are shown. None of the clinical variables showed significant variation comparing baseline and follow-up period.

Table 1. Clinical characteristics





After 4 appointments




Ejection fraction*, % ± SD


32 ± 11


35 ± 10




Functional status, n (%)

 SAS I, II, III and IV


28(47) 25(42) 6(10) 1(1)


34(57) 15(25) 9(15) 2(3)



Sodium mmol/L

136 ± 3.1

138 ± 3.2


Potassium mmol/L

4.5 ± 0.6

4.4 ± 0.6


Creatinine mg/dL

1.0 ± 0.3

1.0 ± 0.4


Urea mg/dL

55 ± 37

64 ± 53


* Only 37 patients had new assessment of ejection fraction at follow-up.
SD: standard deviation; SAS: Status Activity Scale; Pearson Chi-square; Student’s t test


Understanding of the disease and treatment: Prior to the first assessment, 33% of the patients understood the disease well, the risks and the treatment proposed. After 4 appointments there was a significant increase in the number of patients improving their knowledge in these issues, (55%) (P=0.006). Table 2.

Weight control pattern: All patients were asked about how often they used to weigh themselves. It was possible to observe significant improvement on the number of patients who controlled their weight regularly (P=0.002), as well as a significant increase of the frequency of this control during the week (P=0.01) after 4 appointments. Table 2.

Meaning of weight gain and fluid retention: Patients were questioned about what could be involved in gaining of weight in a short time. Although without significant differences, after 4 appointments more patients could relate the gain of weight in a short time with fluid retention. Table 2

Understanding drugs used: The patients were asked about what they knew about the drugs they were prescribed. From the first to the last appointment, around 70% of the patients knew approximately 50% of the drugs names. No difference was observed in this regard (data not shown).

Non-pharmacological care: Patients were asked about additional care which should be followed in association with taking medications regularly. The three procedures included fluids and salt control and physical activities on a regular basis. These results show a significant improvement (P=0.01) after the 4 appointments.

Non-pharmacological daily control: With the nurses follow-up all this non-pharmacological control was performed more frequently (P=0.02). All these results are showed on Table 2.  

Table 2. Knowledge of the disease and self-care




After 4 appointments



Understanding of the disease

Understanding risks and the treatment n (%)

Understanding some aspects or not n (%)


20 (33)


40 (67)


33 (55)


27 (45)



Weight control


Yes n (%)

No n (%)




27 (45)

33 (55)



43 (72)

17 (28)




Weight control and frequency during the week

More than 3 times n (%)         

 Less than 3 times n (%)



39 (65)

21 (35)



45 (75)

15 (25)




Meaning of weight gain and fluid retention

Yes, fluid retention n (%)

Do not know n (%)



31 (52)

29 (48)



40 (67)

20 (33)




Perform Non-pharmacological care

Fluids, salt and physical activities n (%)

Do not perform n (%)


17 (28)


43 (72)


30 (50)


30 (50)



Frequency of non-pharmacological daily control

Frequently n=55 (%)

Sometimes or never n=55 (%)

38 (63)


22 (37)

48 (80)


12 (20)


* Pearson Chi-square


Heart failure is a chronic disease that causes impact on the physical and psychological well being. The restrictions on the daily activities are the result of the progression of the disease, which has an implication on the quality of life of heart failure patients (2). Since the first randomized clinical study demonstrated positive outcomes on the reduction of rates of readmission, reduction of costs and improvement on the quality of life with approach included systematic education about the disease, recognition of signals and symptoms of decompensation and importance of adherence to medication and self-care (8). The results of the present study demonstrated that patients when referred to a first nurse assessment with CHF showed insufficient knowledge about their disease and the self-care. Just 33% understood well the disease, risks and the treatment provided by medical team. Some results from other investigators also suggested this scenario (7, 9). For example, in a classic   an European study, Jaarsma et al demonstrated in a randomized study with an intensive education to self-care versus usual care, the patients who were in an intervention group showed and improvement on their self-care behavior (10). Recently, Stromberg et al randomized 106 patients to follow-up after the hospital discharge by specialist nurses in CHF with home-care visits, to provide an education about the disease and self-care, to evaluate the patient and the suggested treatment. The main outcomes of this study demonstrated a significant improvement on the scores of self-care in the intervention group, decrease rates of events (death or hospital readmission) and days in hospital (11). Regarding weight control, after 4 nursing appointments at follow-up, patients began to weigh themselves more often. Regarding weight, although no significantly, our data demonstrated that 64% of these patients after 4 nurses appointment, related the increased of the weight in a few days with a fluid retention.  The increase of corporal weight in 1.3 Kg-2.2 Kg in a week would indicate that there was a fluid retention (12). Data from the literature demonstrated to be difficult to the patients to relate the suitable gain of weight with CHF worsening or changes in their health state (13). Similar results were presented by Stromberg et al (11) when there was a significant improvement in the weight control on the intervention group compared to the control group in 3 to 6 months of 35% to 79%.

Concerning to regular use of medication, as well as the knowledge of the importance of adherence, patients knew more about the fluid control, of diet salt control and the regular physical activities (50%) as being part of a non pharmacological treatment, and these actions were more frequently taken by most of the patients (80%). Recently on a review article it was demonstrated a rate of non adherence of sodium restriction around 50-88%, and that the adherence to self-care, including the diet, showed a significant improvement related to the knowledge (6). In a study published by Neily et al 50 patients with CHF were evaluated regarding knowledge about the disease, regarding fluid and sodium control and the recognition of food with abundance of sodium. After the follow-up the orientation by a nutritionist, patients started to understand better the importance of the low sodium diet on the management of the disease, as well as recognition of food containing high amounts of sodium, and that latter should not to be included in their daily habits (14). These data showed that nurses’ intervention that aim at the importance of knowledge about the disease and the self-care are essential to manage these patients. Specific strategies to recognize the symptoms and the relation of these with the worsening of the functional class and non compliance to the treatment should be taught pharmacological management in heart failure include modification in the lifestyle as well as the diet, weight control, regular physical activities and the monitorization of the signals of decompensation. The insertion of the patient and the family in a multidisciplinary team should provide the understanding and the compliance of regular use of medication and the practice of self-care.

Recently a European study similar to the one conducted by our team, evaluated 298 outpatients who had been followed during 1 year by nurses on education and treatment of the CHF. These authors have reached positive outcomes concerning weight and blood pressure control.  However, there was no adherence to salt restriction and little to physical activities (5).

Implications of the practice

The main goal of education in a patient with a chronic disease such as CHF and their caregiver is to make them understand the process of the disease. The signals and symptoms of the decompensation and all the aspects involved in the adherence to the procedures include skills to self-care, for instance the restriction of liquids, salt, exercise, daily weighing, regular use of medication, monitorization of signals and symptoms of the worsening of CHF.

The combination of the perception by the team to the patient’s needs and their learning skills concerning self-care may lead to positive results.


In conclusion, the current study suggest that systematic education with follow-up by nurses as part of the multidisciplinary team to provide increase in patient’s understanding about the disease and the behavior to self-care. This approach together with others strategies could decrease readmission rates of HF and consequently bring a better quality of life for patients with heart failure. Finally, potential reductions in health costs related to HF could be achieved.


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2.         Krumholz HM, Amatruda J, Smith GL, Mattera JA, Roumanis SA, Radford MJ, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol 2002; 39:83-9.

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11.       Strömberg A, Martensson J, Fridlund B, Levin L-A, Karlsson JE, Dahlström U. Nurse-led heart failure clinics improves survival and self-care behavior in patients with heart failure. Results from a prospective, randomised trial. Eur Heart J 2003; 24:1014-23.

12.       Silver MA, Cianci P, Pisano CL. Outpatient management of heart failure-program development and experience in clinical practice. Illinois: The heart failure institute and heart failure center; 2004. Report No.: 2.

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14.       Neily JB, Toto KH, Gardner EB, Rame JE, Yancy CW, Sheffield MA, et al. Potential contributing factors to noncompliance with dietary sodium restriction in patients with heart failure. Am Heart J 2002; 143:29-33.

- Concepção e desenho: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun , Solange Braun Gonzalez. - Análise e interpretação: Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun , Solange Braun Gonzalez. - Escrita do artigo: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun.- Revisão crítica do artigo: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun , Solange Braun Gonzalez.- Aprovação final do artigo: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun , Solange Braun Gonzalez.- Colheita de dados: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun , Solange Braun Gonzalez.- Provisão de pacientes materiais e recursos: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun , Solange Braun Gonzalez.- Expertise em Estatística: Eneida Rejane Rabelo - Pesquisa bibliográfica: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel.- Suporte administrativo, logístico e técnico: Eneida Rejane Rabelo, Graziella Badin Aliti , Fernanda Bandeira Domingues, Karen Brasil Ruschel, Anelise Oliveira Brun , Solange Braun Gonzalez.

 Eneida Rabelo
Serviço de Cardiologia
Rua: Ramiro Barcelos, nº 2350, sala 2060 CEP: 90035-903.
Phone: Fax: 51-21018843; 51-21018657

Received: Jul 13, 2007
Revised: Oct 14, 2007
Accepted: Oct 25, 2007