Capstone FINAL

Running head: ASSESSMENT OF RN CASE MANAGERS KNOWLEDGE OF 1
Assessment of RN Case Managers Knowledge of Current Evidence-Based Nutritional Guideline
Recommendations for Heart Failure Patients
Brittany Rose BSN, RN, CCM
Western Governors University
A Capstone Presented to the Nursing Faculty
of Western Governors University
in Partial Fulfillment of the Requirements for the Degree
Master of Science in Nursing, Leadership and Management
February, 2015

ASSESSMENT OF RN CASE MANAGERS KNOWLEDGE OF 2
Assessment of RN Case Managers Knowledge of Current Evidence-Based Nutritional Guideline
Recommendations for Heart Failure Patients
Abstract
The purpose of this study was to assess RN Case Managers’ knowledge of current evidence-
based nutritional guideline recommendations for heart failure patients to determine if there was
a knowledge deficit that leadership should consider addressing. The study included 33
participants all employed with the researcher at the host organization. The researcher created a
17-question assessment including questions evaluating demographic information, evaluation of
confidence level teaching the research topic, policy at the host organization, and clinical
guideline questions. Evaluation of the assessment results revealed a pronounced knowledge
deficit among nurse Case Managers at the host organization. Six of the 17 questions were
clinical guideline based and of the six, no single question had a majority of participants
answering correctly. After evaluation of participant answers to the 17-question assessment, the
researcher was able to ascertain an urgent need for additional education to provide updated
clinical guideline information on current evidence-based practice guidelines for heart failure
patients.

Acknowledgements
When I started the capstone journey I will admit I thought I would not need to enter any
“acknowledgements” but I now see why they put this in as part of the assignment. No family can
go unrecognized during a capstone and I would like to say thank you to my supportive husband,
no matter how much I believed I could not finish this and that it was the most difficult thing I
ever had to do, he simply told me “it will all work out”. The funny thing is, he was right, no
matter how much I cried and stressed myself to the max insisting it was the end of the world, he
would say, “this too shall pass”. Most of the time when he said these things to me I wanted to
throw something at him. As many times, as he had to talk me off the ledge, one would think I
would no longer be terrified of heights. I am so blessed to have someone that in worse case
would go tandem with me off that ledge, my husband encouraged me to move on for my degree
so he could see me “hooded” because he thinks I do so much as a nurse I deserve that part. I
think he just wants something that is big enough to catch all my tears when I pursue additional
education.

Table of Contents
Abstract………………………………………………………………………………………2
Acknowledgements…………………………………………………………………………..3
Table of Contents…………………………………………………………………………….4
List of Tables…………………………………………………………………………………9
List of Figures……………………………………………………………………………….10
Chapter 1: Introduction to the Problem …………………………………………………... 9
Introduction …………………………………………………………………….…....... 9
Presentation of Topic …………………………………………………………………. 10
Explanation of Topic………………………………………………. 11
Project Importance ……………………………………………………….…………….12
Problem Outline …….…………………….………...………………………………….13
Background Information …….…………..…………………………………...………...14
Causes………………………………………………………………………………….. 15
Research Question(s)……………………………………………………………………16
Best Practices Research………………………………………………………………....16
Chapter 2: Literature Review………………………………………………………………20
Research Question………………………………………………………………………20
Introduction ……………………………………………………………………….……21
Non-Pharmacological Prescriptions ………………………………………….………...22
Sodium………………………………………………………………………………23
Fluid……………………………………………………………………………........24
Barriers Effecting Implementation……………………….………………………......…25

Methodologies to deliver self-management education……………………………..........25
How patients process education... ……………………………………………………….25
Psychosocial barriers…………………………………………………………….............26
Behavioral and cognitive barriers……………………………………………………......26
Educating Nurses………………….………………………………………………………....27
Influencing factors determining the need for nurse education……………………...........27
Barriers to continuing education…………………………………………………………28
Time Constraints…………………………………………………………………………29
Leadership Support……………………………………………………………………....30
Conclusion ……………………………………………………………………………………....30
Chapter 3: Methodology………………………………………………………………………...32
Introduction …..………………...…………………………………………………………....32
Evaluation Tools and Methods………….…………………………………………………...32
Tools……………………………………………………………………………………..32
Methods………………………………………………………………………………….32
Reliability and Validity…………………………………………………………………..35
Integrity of Data and Data Use……………..………………………………………………..35
Research Design……………………….……………….…………………………………….35
Research Method…………………………..………………………………………………...36
Explanation of Research Method ………………………………………………………..36
Participants……………………………………………………………………………….......37
Permissions………………………………………………………………………………......37
Summary…………………………………………………………………………………......37

Chapter 4: Findings……………………………………………………………………………...39
Outline of Results …..………………………………….……………………………………39
Statement of Results…………………………………………………………………………39
Analysis...……………………………………………………………………………………40
Analysis of Demographic data……………………………………………………..………..40
Age, sex, role in organization……………………………………………………………40
Education, experience as a nurse and telephonic RN, and certification……………...…41
Clinical Based Questions…………………………………………………………….….43
Confidence of participants……………………………………………………………….43
Process at host organization………………………………………………………………….45
Host organization’s current clinical guidelines…………………………………………45
Clinical guidelines used at host organization…………………………………………....45
Clinical Guideline Questions………………………………………………………..……….46
Sodium intake for stage A and B heart failure…………………………………………...46
Sodium intake for Stage C and D heart failure……………………………………...…...47
Average sodium intake of general population……………………………………….…..47
Nurses prepared as educators for heart failure……………………………………….…47
High sodium foods…………………………………………………………………….…48
Sodium guideline recommendation for hypertension……………………………………49
Fluid intake for advanced heart failure patients……………………………………..….50
Research Question Answer ……………………………………...……………..…………....51
Summary……………………………………………………………………………………..52
Chapter 5: Discussion and Conclusions……………………………………………………….…53

Project Overview…………………………………………………………………………….53
Summary of Findings…………………….……………………………………………...53
How were results obtained…………………………………………………………….....53
Possible Solutions …………………………………………………...………………………54
Implications and Limitations…………………………………………………………...……54
Strengths…………………………………………………………………………..……..55
Weakness…………………………………………………………………………...……56
Problems…………………………………………………………………………………56
Factors…………………………………………………………………………………...56
Improvements………………………………………………………………………………..57
Further investigation……………………………………………………………………..58
What to do differently……………………………………………………………………59
Justification of differences……………………………………………………….59
Master’s Degree Experience.………………………………………………………………...59
Application in Work Environment…………………………………………………………...59
References ………….……………………………………….…………………………………...61
Appendices ………….……..……………………….……….…………………………………...69
Appendix A: Assessment of RN Case Managers’ Knowledge of Current Evidence-Based
Nutritional Guidelines………………………………………………………………………..69
Appendix B: Informed Consent………………...……………………………………………75

List of Tables
Table 1- Participant Demographic Data: Age…………………………………………………...41
Table 2- Participant Demographic Data: Sex…………………………………………………....41
Table 3- Participant Demographic Data: Role in the Host Organization………………………..41
Table 4- Level of Education in Nursing………………………………………………………....42
Table 5- Years of Experience Working in the Nursing Profession……………………...………43
Table 6- Years of Experience Working as a Telephonic Case Management Nurse…………….43
Table 7- Certified as Case Manager……………………………………………………………..43

List of Figures
Figure 1- Participant Confidence Level in Heart Failure Nutrition……………………………44
Figure 2- Sodium Intake for Stage A and B Heart Failure………………………………...…...45
Figure 3- Sodium Intake for Stage C or D Heart Failure………………………………………46
Figure 4- Average Sodium Intake by the General Population…………………………………47
Figure 5- High Sodium Foods…………………………………………………………………48
Figure 6- Sodium Guidelines for Hypertension Patients………………………………………49
Figure 7- Fluid Restriction for Heart Failure Patients…………………………………………50

Chapter 1: Introduction to the Problem
Introduction
Heart failure (HF) describes a condition where the heart cannot fill properly with blood
and/or pump effectively enough to circulate blood through the body properly (National Heart,
Lung, and Blood Institute [NHLBI], 2014 & Yancy et al., 2013). HF is a burden on the health
care system and the American Heart Association (AHA) projects that over the next 20 years the
real time medical expenses associated with heart failure will increase by approximately 200% if
cardiovascular disease is not adequately controlled (Heidenreich et al., 2011). Making an impact
on these staggering statistics is contingent upon whether patients can effectively manage their
condition without constant health care professional supervision. Patients are responsible for
implementing the necessary self-management skills to manage their HF and providing patients
with the necessary education for effective self-management is the responsibility of the health
care team, more specifically, the nurse.
The American College of Cardiology and the American Heart Association (ACCF/AHA)
2013 HF Guidelines indicate that patients must be educated on self-care for improved patient
outcomes; education on self-care involves educating about self-management skills. Self-
management skills include several non-pharmacologic interventions such as monitoring for
symptoms of fluid retention, weight fluctuations, restriction of dietary sodium and fluid, taking
prescription medications as instructed, and staying physically active (Boren, Wakefield,
Gunlock, & Wakefield, 2009; Riegel et al., 2009; Yancy et al., 2013). Management of fluid
retention symptoms, fluctuations in weight, and maintaining the ability to stay physically active
all seem to hinge on one very important self-management skill: adherence to nutritional
guidelines. The CDC (2013) lists three self-management skills that heart failure patients can

take to prolong their life and improve overall quality of life; one of the three is nutrition, more
specifically, management of dietary sodium (Centers for Disease Control and Prevention [CDC],
2013).
According to Alves, Souza, Brunetto, Peggy, and Biolo (2012), patients lacking the
important details about restrictions and limitations are likely to have poor management of their
heart failure. Poor self-management skills are associated with poor quality of life (QoL) for HF
patients however, several studies indicate that patients participating in nurse-led education
programs that focus on self-care exhibit improved QoL. Patients who have an increased
understanding of their heart failure are demonstrate an improved QoL and increased ability to
implement prescribed non-pharmacologic interventions (Albert, 2012; Boren et al., 2009; Riegel
et al., 2009; While & Kiek, 2009).
Presentation of topic. Increased utilization of evidence-based practice has brought
attention to the lack of research supporting non-pharmacological approaches to management of
heart failure. In addition to the lack of available research for previous and current guidelines
there is a growing recognition of knowledge deficit among nurses regarding evidence-based
approaches for management of HF (Albert, 2013; Johansson, Fogelberg-Dahm, & Wadensten,
2010; Washburn & Hornberger, 2008). The American College of Cardiology and the American
Heart Association (ACCF/AHA) revised the self-management nutritional recommendations for
heart failure (HF) in 2013 making the nutritional guideline recommendations increasingly vague.
The previous ACCF/AHA guidelines, while more specific, included minimal research supporting
the recommendations. The new recommendations offer general guidance for practitioners but
make the need for additional research overwhelmingly obvious.

Nurses are pivotal in providing the necessary education to HF patients for managing their
condition, placing emphasis on interventions associated with improved patient outcomes namely,
nutritional guidelines recommendations. Diet is the most commonly prescribed non-
pharmacological nutritional recommendation and sodium limitation is the most common dietary
recommendation, followed by fluid restriction (Linhares, Alti, Castro, & Rabelo, 2010).
Focusing on nutrition is an excellent place to start since it is associated with improved healthcare
outcomes for HF patients (Boren et al., 2009).
Case Managers (CM) are not always nurses but in this research project, the CMs
participating in the research project are all RNs CMs. A CM has a multifaceted role that
encompasses many aspects of the health care system requiring excellent communication and
collaboration skills. CMs are responsible for collaborating with multidisciplinary team members
and developing interventions to meet the complex needs of patients (Commission of Case
Management Certification, n.d.). Telephonic RN CMs at the host organization have the same
responsibilities as a CM, with the exception of performing the role solely through telephone calls
to patients, physicians, and ancillary providers (UnitedHealth Group [UHG], 2014).
Explanation of topic. Heart failure is a silent and progressive disease, setting it apart
from other chronic illnesses, creating a barrier to adherence of self-management behaviors that
are vital to the survival of HF patients (Albert, 2013). The disease’s progressive nature often
results in unexpected, rapid deterioration, subsequently the need to re-evaluate and change the
patient’s self-management plan is inevitable, and consequently these frequent changes are
associated with a decrease in the ability to make behavior change on a long-term basis
(Smeulders et al., 2010).

Patients lacking the important details about restrictions and limitations are likely to have
poor management of their heart failure (Alves, Correa Souza, Brunetto, Schweigert Perry, &
Biolo, 2012). Ironically while studies reveal patient non-adherence to prescribed non-
pharmacologic care is an issue, studies also reveal that the nurses providing inpatient care to
heart failure patients adhere to less than half of the non-pharmacologic prescribed care (Linhares,
Alti, Castro, & Rabelo, 2010).
Heart failure is undeniably the most common cause of hospitalizations and with a desire
for patients to effectively self-manage, their condition puts nurses in an important role of
educating about all aspects of heart failure with an emphasis on those interventions associated
with improved heart failure patient outcomes (Boren et al., 2009). Son, Lee, & Song (2011)
researched the effects of dietary restrictions particularly the sodium restriction diet (SRD) and
were able to show correlation that symptoms were greater when patients did not adhere to the
SRD thus making a need for proper education to patients to help them better understand self-
efficacy.
The ACCF/AHA establishes current nutritional guideline recommendations according to
the patient’s stage of HF. Currently the ACCF/AHA recommends a sodium restriction of
1500mg/day for patients with Stage A & B HF, whereas the recommendations for Stage C & D
is less than 3000mg/day and there is limited research supporting the recommendation (Yancy et
al., 2013).
Linton & Prasun (2012) state that it is a patient’s right to receive the most current, high
quality evidence-based care, compelling nurses to ensure that the education and information
provided is exactly that.

Project importance. Currently in nursing, there is a lack of consistency in what nurses
are teaching patients regarding self-management nutritional guidelines for HF, largely due to
nurses own lack of knowledge (Albert, 2013). Expecting nurses to educate patients about
behavior modifications responsible for improving management of HF is not realistic when the
nurse is lacking current information on the topic.
Nurses responsible for educating patients with HF are not always confident with the
amount of knowledge they possessed regarding HF self-management creating a need for
assessing what deficits exist (Albert, 2013; Washburn & Hornberger, 2008). The researcher’s
project includes an assessment tool designed to identify deficits among RN CMs responsible for
educating HF patients at the host organization. Identifying knowledge deficits among nurses is
necessary before creating and implementing effective and relevant interventions to educate the
RN CMs. It is essential for nursing leadership to understand the nurses’ level of knowledge
when attempting to create best practice guidelines and to create an environment that supports
integration of evidence-based practice for increased success (Albert, 2013; Linton & Prasun,
2013).
Providing nurses with an assessment tool evaluating level of knowledge regarding the
most current evidence-based practice nutritional guideline recommendations for HF prompts RN
CM reflection on what they currently consider and incorporate into their heart failure
discussions. After completion of the study, supplying RN CMs and leadership with both answers
and relevant resources allows for additional review of current evidence-based practice
information and hopefully can lead to additional educational assessments helping nurses identify
with knowledge deficits.
Explanation of the Problem

Problem outline. Currently the Heart Failure Society of America, European Society of
Cardiology, Canadian Cardiovascular Society, ACCF/AHA, Scottish Intercollegiate Guidelines
Network, and American Dietetic Association all vary on guideline recommendations for dietary
sodium and fluid restrictions (Gupta et al., 2012 & Lennie et al., 2011). Dietary sodium
restriction, fluid limitations, and weight management is acknowledged by many researchers as
being essential for improved outcomes in HF patients but without the recommendations being
communicated to the nurses responsible for educating patients these improved outcomes may not
be achieved (Albert, 2013; Gupta et al., 2012; Linhares, Alti, Castro, & Rabelo, 2010 & Yancy et
al., 2013).
According to Albert (2013), nurses responsible for educating HF patients were not always
confident with the amount of knowledge they possess regarding HF self-management, such as
weights, diet, and exercise and the amount of research available addressing the issues is scarce.
Identifying knowledge deficits among staff nurses at the host organization is necessary before
creating and implementing interventions addressing the identified deficits. It is essential for
nursing leadership to understand that their nurses level of knowledge when attempting to create
best practices (Albert, 2013).
RN Case Managers (RN CM) not having current knowledge of evidence-based nutritional
guideline recommendations for HF may have a negative impact on the confidence patients have
in the nurse responsible for providing them with the necessary education. The researcher is
assessing RN CMs knowledge of evidence-based nutritional guideline recommendations for HF
because it is likely that these RNs CMs are also lacking the necessary information for effective
patient education as previously mentioned (Albert, 2013). The time it can take to access
documents containing updated information or the confusion involved in interpreting the changes

may result in RN CMs redirecting their time to other aspects of their role i.e. heavy caseloads,
resulting in continued use of out dated information when educating patients. RN CMs must
continue education and learn how to interpret research if it is an area the RN CM is not
confident. The need for RN CMs is growing and continues to grow with health care reform and
the increase in age and complexity of patient needs making ongoing education increasingly
important for effective patient management (Tahan & Campagna, 2010; Tansey, 2010).
Background information. Inconsistencies with non-pharmacological interventions
prescribed for HF patients is prompting further review of literature in attempts to have a solid
foundation of what is safe information for HF patient education. For example, specific sodium
restrictions have been associated with non-pharmacological prescriptions in self-management of
HF patients; however, locating evidence supporting this common non-pharmacological
prescription has mixed findings (Linhares, Aliti, Castro, & Rabelo, 2010; Son, Lee, & Song,
2011). Linhares, Aliti, Castro and Rabelo (2010) identified that nurses were not carrying out the
prescriptions of the non-pharmacologic interventions, another reason for evaluating literature
associated with nurse knowledge and delivery of nutritional interventions.
Determining if a particularly methodology of self-management/self-care education
resulted in increased level of success is another area of intrigue to be researched. While and
Kiek (2009) discuss a study by Kutzleb and Reiner (2005), evaluating HF patients’ quality of life
(QoL) after nursing intervention involving patient education and found that self-efficacy is
dependent on the education by nurses. The outcome of the Kutzleb and Reiner (2005) study
demonstrated improvement in QoL, as well as evidence of increased self-management associated
with patients feeling empowered after receiving information and educational interventions

regarding their condition. Being able to improve QoL of HF patients would be life changing to
those patients struggling with self-management.
Factors influencing the need for additional education of nurses caring for HF patients was
identification of nurses not being as knowledgeable as expected when presenting evidence-based
information to patients and furthermore, the nurses not realizing their lack of knowledge
regarding guidelines, until surveyed in research studies is an important factor to consider (Albert,
2013; Higgins, Navaratnam, Murphy Walker, & Worcester, 2013). The researcher has concerns
that RN CMs at the host organization experience the same issues as identified above but there
have not been assessments distributed to nurses to begin to explore these likely deficient areas in
their practice. The researcher is hoping this research project will prompt further investigation
into gaps in knowledge of HF as well as other chronic health conditions.
Possible causes of the problem. A barrier to finding evidence-based dietary education
and interventions with a target audience of HF patients can be challenging because of the
obstacles encountered when measuring outcomes of diet intervention (Donner Alves et al.,
2012). Being in a controlled environment such as a hospital for a controlled kitchen environment
is not practical making accurate record keeping difficult for patients in their normal environment.
Health literacy is also a barrier to a HF patient’s ability to self-manage their condition (Chen et
al., 2013; Smeulders et al., 2010).
Albert (2013) states that heart failure is a silent and progressive disease, setting it apart
are vital to the survival of a HF patient. The disease’s progressive nature often results in
unexpected, rapid deterioration, subsequently the need to re-evaluate the patient’s self-

management plan is inevitable, and consequently these frequent changes are associated with a
decrease in the ability to make behavior change on a long-term basis (Smeulders et al., 2010).
The success of nurses being able to provide evidence-based non-pharmacologic
intervention for HF patients relies on the education of the nurses responsible for providing the
education (Albert, 2013). Albert (2013) acknowledges that while nurses may demonstrate basic
knowledge of HF patient education, additional research revealed that the nurses were not
comfortable providing education to patients about the topic, thus promoting the need for
intervention by leadership. The research demonstrates nurses’ reporting fewer barriers resulted
in a greater number of practice changes, and vice versa, and decreased number of barriers
resulting in less practice changes (Higgins et al., 2013). There was presence of a substantial
correlation between nurse self-efficacy and the perception of barriers. Accordingly, nurses
reporting greater self-efficacy reported a decreased number of perceived barriers four months
after the educational intervention. There was no marked correlation between self-efficacy and
the number of perceived barriers before or four months after the educational intervention, and
associating the amount of practice changes with nurse self-efficacy reports was not possible
(Higgins et al., 2013).

Chapter 2 Literature Review
Research Question(s)
What is the RN Case Managers’ current knowledge of evidence-based nutritional guideline
recommendations for heart failure patients?
Best Practices Research
Best Practices for effective non-pharmacological interventions. Best practice research
associated with nutritional guideline recommendations for heart failure patients involves review
of effective non-pharmacological interventions for HF patients; effective delivery techniques of
self-management education to HF patients; and best practices for nurses to overcome their own
identified knowledge deficits and level of self-efficacy regarding nutritional guideline
recommendations for HF.
Best practice for HF non-pharmacological interventions (NPI) is first evaluating the
patient’s perception of what self-management includes and their perception of what self-
management skills they currently possess. Utilizing education materials tailored to individual
educational needs for each patient is associated with improved quality of life and an increased
level of understanding about their condition(s) (Kato et al., 2012; While & Kiek, 2009). An
evidence-based practice intervention is providing tools or teaching how to create tools for
tracking dietary intake and dietary interventions helps a patient advocate for themselves and is a
best practice to incorporate into patient HF education (Leone, Walker, Curry, & Agee, 2012;
While & Kiek, 2009).
Best practices for effective self-management education. A best practice for providing
self-management education is creating and delivering culturally specific education. A pilot study
in Japan revealed that creating cultural specific, self-care education for the Japanese heart failure

population demonstrated favorable outcome with proven comprehension of heart failure
information. Those same patients indicated they would appreciate educational materials that
include information describing signs and symptoms signifying fluid overload with direction on
when they are justified in contacting their providers, prognosis, and indicate their level of
activity (Kato et al., 2012). The United States Census Bureau indicates the United States
population is currently comprised of 62.6% Caucasians; leaving 37.4% of the population
consisting of various cultural backgrounds and beliefs, developing culturally specific heart
failure literature is beneficial to the health care community (Kato et al., 2012; United States
Census Bureau [U.S. Census Bureau], 2014).
Using skills that patients can implement into their day-to-day lives is what makes an
impact on adherence to outcomes (Dickson & Riegel, 2009). Suggestions include involving
role-playing when discussing foods with hidden, high sodium content, having patients choose
which foods would be most appropriate for their diet and creating a diet from these activities.
Best practice for training of nurses. The effective design and the administration of a
HF training program for nursing designed by the Heart Research Centre was key to nurses
addressing and overcoming the barriers of self-efficacy, perceived barriers, and practice change
by developing an increase in nurses’ confidence that are responsible for educating HF patients
(Higgins et al., 2013). Albert (2013) discusses best practices designed to overcome the time and
comfort barriers for nurses by making the necessary educational information available via one
hour, computer based self-studies. Managing the barrier of time is achievable, requiring minimal
time for completion of the self-studies by focusing on the areas determined via survey, to be the
weakest and least taught areas of self-care education for HF patients by the nurses (Albert,
2013).

Suggestions to encourage EBP by Linton & Prasun (2013) include creating clubs for
nurses to meet on a regular basis to review literature and implement the research into the unit’s
guidelines; establish routine meetings on the unit to review evidence and discuss relevance to the
unit; and collaboration among staff and other departments to implement research among the
facility.
Literature Review Introduction
A search utilizing the Cumulative Index to Nursing and Allied Health Literature
(CINAHL), MEDLINE Plus Full Text, Health Business Elite, and the American Heart
Association databases for (2009-2014) peer reviewed scholarly articles, scientific and policy
statements eluted to a vast number of articles relevant to the researcher’s topic. Using the
combination of search terms; BOOLEAN/Phrase: heart failure, nutrition, and nursing; heart
failure and non-pharmacological; heart failure and sodium; heart failure and fluid successfully
provided articles narrowed down to the focus of the research topic addressing the knowledge RN
Case Managers possess regarding nutritional recommendations for heart failure and best
practices associated with the topic.
Identifying non-pharmacological prescriptions to include in self-management education
as well as identifying barriers possibly interfering with adherence to the prescriptions is
fundamental when trying to develop effective interventions to manage heart failure exacerbation.
This review of literature conveys the most relevant and up to date information for nurses
regarding evidence based, non-pharmacological nutritional recommendations for HF patients.
The researcher is synthesizing current research from 2008 and beyond, informing the reader of
what is known of the topic but taking note to discuss what is unknown regarding the topic as
well.

Non-Pharmacological Prescriptions
Effective management of any chronic condition relies on self-management skills,
effective management of HF involves adhering to non-pharmacologic self-care behaviors such as
dietary restrictions; exercising; weighing daily as a method to monitor for signs of fluid overload
(Riegel et al., 2009; While & Kiek, 2009). Inconsistencies with non-pharmacological
interventions prescribed for HF patients is prompting further research in attempts to have a solid
foundation of what is safe information for HF patient education. For example, specific sodium
restrictions have been associated with non-pharmacological prescriptions in self-management of
HF patients; however, locating evidence supporting this common non-pharmacological
prescription has mixed findings (Linhares, Aliti, Castro, & Rabelo, 2010; Son, Lee, & Song,
2011). Linhares et al. (2010) identified that nurses were not carrying out the prescriptions of the
non-pharmacologic interventions, another reason for evaluating literature associated with nurse
knowledge and delivery of nutritional interventions.Two of the most commonly prescribed non-
pharmacologic nutritional recommendations are sodium restriction and fluid restrictions
(Linhares et al., 2010).
Sodium. Sodium restrictions have been associated with non-pharmacological
prescriptions in self-management of HF for many years; however, locating evidence supporting
this common non-pharmacological prescription reveals mixed findings (Linhares et al., 2010;Son
et al., 2011; Washburn & Hornberger, 2008). Many articles, that include the key words diet and
heart failure, reference the topic of sodium intake and its effect on heart failure, the topic may be
those supportive of a low-sodium diet or those that argue against strict sodium restriction, but it
seems to be a common theme among these key words.

Nurses should consider varying factors that may interfere with patient adherence to a
sodium-restricted diet when making the self-management recommendations. Identifying a
patient’s knowledge of sodium-containing foods, other sources of sodium, and ability to
incorporate low-sodium diet into their lifestyle are factors that contribute to successful adherence
(Arcand et al., 2011). The consumption of pre-packaged foods and fast foods is repeatedly
mentioned in various studies as the reason for insidious sodium intake among HF patients (Alves
et al., 2012; Philipson, Ekman, Swedberg, & Schaufelberger, 2010; Son et al., 2011). Patients
being able to comprehend and correlate the effects of consuming excessive sodium and feeling
poorly are associated with greater adherence to the recommendations (Son et al., 2011; Welsh et
al., 2010).
The host organization utilizes the most current ACCF/AHA Guidelines as the standard
for all HF clinical recommendations within the organization (UnitedHealth Group [UHG], 2014).
The 2013 ACCF/AHA HF Guidelines recommend a 1500mg/day sodium restriction for patients
with both stage A & B HF; however, stage C & D recommendation are vague at <3 g/day
because of the minimal research available to indicate otherwise at this time (Yancy et al., 2013).
Sodium consumption in the general population is estimated by the ACCF/AHA as being more
than 4,000mg/day creating a seemingly large gap in what is recommended and what is actually
consumed (Yancy et al., 2013).
Fluid. Much like sodium, research involving fluid management and the effect on HF is
limited and outdated resulting in what recommendations are available among recognized
organizations throughout the world are inconsistent (Gupta et al., 2012). The 2013 ACCF/AHA
Guidelines support restriction of fluid to 1.5-2L/day for patients with advanced HF, also known
as Stage D, with the goal being to manage hyponatremia and reduce risk of HF exacerbations

(Yancy et al., 2013). A prospective study published by the European Heart Journal in 2010 is
one of the first studies of its nature; the findings indicate that fluid management, as well as other
non-pharmacologic interventions, are associated with having a direct adverse effect on HF
patient outcomes (Van der Wal, Van Veldhuisen, Veeger, Rutten, & Jaarsma, 2010).
Barriers Affecting Implementation
Identifying specific barriers that may be interfering with the ability of a HF patient to
effectively implement the self-management education is important in being able to increase
adherence. While studies are limited in, the area of non-pharmacological interventions and the
outcomes associated with adherence or lack thereof Van der Wal et al. (2010) conducted a study
that proved an important valuable point, which is that adverse outcomes area associated with
whether patients adhere to non-pharmacological recommendations.
Methodologies to deliver self-management education. Determining if a particularly
methodology for self-management/self-care patient education results in an increased level of
success is another area of intrigue to be researched. While and Kiek (2009) discuss a study by
Kutzleb and Reiner (2006), evaluating CHF patients’ quality of life (QoL) after nursing
intervention involving patient education, results support the concept of self-efficacy being
dependent on education by nurses. The outcome of the Kutzleb and Reiner (2005) study
demonstrated improvement in QoL, as well as evidence of increased self-management associated
with patients feeling empowered after receiving information and educational interventions
regarding their condition. Being able to improve QoL of CHF patients may be life changing to
those patients struggling with self-management thus, identifying the teaching methods that are
effective is a crucial barrier to overcome. A review of literature by Barnason, Zimmerman, &
Young (2011) reiterates what other researchers believe, and that is adherence to self-care

improves overall outcomes in HF patients, determining how patients convert what has been
taught by the nurse educators into information they apply in their daily lives is an area to be
researched.
How patients process education. Addressing how patients process the information may
contribute to non-adherence to self-management education. If patients cannot affectively
integrate what they have been educated into their lives then posing the question of whether the
time spent educating was worth it is something to consider. Dickson & Riegel (2009) discuss
concepts not mentioned in such a direct and focused way in other studies. These two authors
identify that the traditional methods used for patient education is not conducive to true
development of skills. Using the terms situational skills and tactical skills as the entire concept
of how patients are educated may solve the non-adherence issue that is so prominent in the heart
failure patient community (Dickson & Riegel, 2009).
Albert (2013) states that heart failure is a silent and progressive disease, setting it apart
are vital to the survival of a CHF patient. The disease’s progressive nature often results in
unexpected, rapid deterioration, subsequently the need to re-evaluate the patient’s self-
management plan is inevitable, and consequently these frequent changes are associated with a
decrease in the ability to make behavior change on a long-term basis (Smeulders et al., 2010).
Psychosocial barriers. Financial hardships interfere with accessing health care, such as
not being able to afford medications, copays for the necessary follow-ups with providers, and
even affording the gas to travel to and from educational classes (Boren et al., 2009). Involving
an assessment of psychosocial needs during the education process may be helpful to the nurse

when tailoring education for patients, being cognizant of the recommendations that involve
costly interventions, such paying for an educational course (Boren et al., 2009).
Review of many self-management programs for HF patients using Watson’s caring
model demonstrated a positive outcomes as a result, the lack of spiritual care application was
determined to be the least integrated into the self-management programs. Perhaps increasing the
incorporation of the spiritual care into the HF programs may increase the success and longevity
in HF patient life according to Lap Tong Leong, Sio Wa Lao, & Hao I Chio (2013).
Behavioral and cognitive barriers. Impairment of cognitive or behavioral function is
another barrier to implementation of interventions for self-management. Depression and anxiety
are behavioral conditions commonly diagnosed in HF patients (Riegel et al., 2009). The typical
signs and symptoms of depression such as fatigue, lack of interest in doing things, feeling
helpless or hopeless may be contributing factors to the poor adherence to self-care.
Remembering to communicate with the patient and any caregivers in a positive manner is
associated with better management of the condition, presenting the information in a manner
perceived as attainable the patient can develop confidence in their abilities to manage their
condition (Welstand, Carson, & Rutherford, 2009).
The ability for the elderly to recognize symptoms is noted in research as being
diminished related to the natural physiological changes that result in a decrease of cognitive
function that occurs with the elderly (Lam & Smeltzer, 2013). The cause of cognitive
impairments can vary from natural aging process, genetic anomalies, to actual anatomical
changes in certain areas of the brain that are directly an effect of HF. Making decisions is an
activity of the prefrontal cortex this area of the brain experiences anatomical changes providing a

valid explanation for the diminished ability to carry out tasks associated with self-management
(Riegel et al., 2009). .
Educating Nurses
Nurses are responsible for demonstrating a level of knowledge that is suitable for caring
for a complex condition, such as HF. A disparity between nursing practice and the utilization of
research into practice is a well-known problem in the nursing community (Johansson, Fogelberg-
Dahm, & Wadensten, 2010). Developing educational interventions for the nurses is a step that is
necessary so nurses are equipped with the knowledge that is directly associated with improved
outcomes.
Influencing factors determining the need for nurse education. Factors influencing the
need for additional education of nurses caring for HF patients include nurses admittedly not
being as knowledgeable as expected when presenting evidence-based information to patients and
the nurses not realizing their lack of knowledge regarding guidelines, until surveyed in research
studies (Albert, 2013; Higgins, Navaratnam, Murphy Walker, & Worcester, 2013). The research
from national and international sources indicates that nurses are not comfortable implementing
evidence-based practice indicating a need for nurse education (Linton & Prasun, 2013).
Medicare performance measures are an area of concern for leaders and educating nursing
staff about education of HF patients and self-management is an area to focus attention. Nurses
generally have the most contact with patients and providing proper education to help patients
better manage their condition resulting in a decrease number of readmission rates (Albert, 2012;
(Kato et al., 2012; McHugh & Ma, 2013).
Barriers to continuing nurse education. The successful implementation and adherence
to evidence-based, non-pharmacologic interventions for HF relies on the abilities of the nurse

responsible for providing the education. While nurses may demonstrate basic knowledge of HF
patient education, additional research reveals that the nurses were not comfortable providing
education to patients about the topic, thus promoting the need for intervention by leadership to
identify and resolve possible barriers (Albert, 2013). Identifying successful educational
techniques for teaching nurses the information necessary for being effective patient educators is
an area of ongoing research but there are studies available creating a foundation for reference by
nurse educators (Higgins et al., 2013; Linton & Prasun, 2013).
A study published by Higgins et al. (2013) investigates potential barriers to successful
education of nurses responsible for teaching HF patients; the study identified a relationship
between the nurses’ self-efficacy, perceived barriers, and their relation to practice change. The
increase in self-efficacy identified among nurse participants is encouraging and speaks to the
creation and delivery of the training program. The success of nurses being able to provide
evidence-based non-pharmacologic intervention for HF patients relies on the education of the
nurses responsible for providing the education (Albert, 2013).
Linhares et al. (2010) demonstrate that nurses perceive their knowledge of evidence-
based practice (EBP) as follows: 61% confident in the confident with being able to review their
own practice, yet 35% reported the ability to convert information into a research question. In the
area of attitudes, nurses report that research is not relevant to their professional practice at 59%
(Linhares et al., 2010). Research by Higgins et al. (2013) demonstrates nurses reporting fewer
barriers resulted in a greater number of practice changes and there was evidence of a strong
correlation between nurse self-efficacy and the perception of barriers. Accordingly, nurses
reporting greater self-efficacy reported a decreased number of perceived barriers four months
after the educational intervention. There was no marked correlation between self-efficacy and

the number of perceived barriers before or four months after the educational intervention, and
associating the amount of practice changes with nurse self-efficacy reports was not possible
(Higgins et al., 2013).
Time constraints. Nurses’ having more complex patients along with an increasing
patient load requirement creates a busy work day for nurses, not leaving much time for reviewing
or discussing literature. (Linton & Prasun, 2013). Nurses want to do the right thing and find
improved ways to carry out a task or procedure but with the lack of time it becomes an ongoing
issue ((Johansson et al., 2010; Linton & Prasun, 2013). Nurse Managers are responsible for
creating an environment supporting of implementation of evidence-based practice among staff.
A review of literature by Johansson et al. (2010) indicates that 73% of the nurses in the literature
reviewed justified time constraints as the greatest barrier for implementation of research.
Support from leadership. Leadership encouraging nurses to further education but no
incentive to do so may be a barrier to having nurses further their education. Furthering nurse
education to the point that they are able to have a true appreciation and understanding for
scientific methodology may bring more nurse to the field that are ready to integrate the new EBP
into practice. Nurses are more open to challenge the way things have been done when they grasp
the concept of EBP; thus, leadership must also be supportive and encouraging to the eagerness
the newly graduated nurse may bring back to the organization with the goals only to better it
(Johansson et al., 2010).
Conclusion
Literature clearly supports the use of EBP: whether it be nurses needing to learn EBP
about the non-pharmacological nutritional recommendations; the EBP associated with educating

the HF patients; or the EBP associated with educating the nurses responsible for educating.
Providing Nurses with the proper tools, whether it be didactic teachings to further their degree;
leadership allocating specific times for nurses to be able to stop working for one hour weekly to
review an assigned article, self-reflect on the article, design research questions associated with
the article. Scheduling small group discussions to review the information may create a sense of
comradery as well as being able to see each other as the contributors and a change-agents.
Without nurses understanding what EBP they are to be teaching patients a gap exists, this
assessment by the researcher identifies areas of missing knowledge. This creates the first steps
of correcting the problem by identifying the gaps in knowledge, investigating barriers, and then
resolving these barriers.
The next chapter, Chapter 3, is discussing methods best suited for the evaluation of the
data collected for this project. Identifying where the gaps in knowledge among RN CM
knowledge of the most current evidence-based practice nutritional guideline recommendations
for HF will help leadership determine what areas they can begin developing educational
information to present to nurses.

Chapter 3: Methodology
Introduction
Assessing RN CM knowledge of the evidence-based practice nutritional guideline
recommendations for heart failure patients and then analyzing the data may help leadership
develop education and training filling the identified gaps. Allowing the RN CMs to access
the research study results after researcher completes the study may be beneficial to the nurse
participants, allowing them to review areas where the department is lacking knowledge and
work as a team to make the necessary changes. The setting of the research project was at a
large health insurance organization in St .Louis, MO. The participants work with the researcher
as telephonic RN CMs and all work in a virtual environment from their homes and completion
of the questionnaires was to be on the nurses’ personal time.
Evaluation Tools and Methods
Tools. The researcher utilized a self-designed questionnaire comprised of seventeen
multiple-choice questions (see Appendix A for the Nurse Assessment Questionnaire) as an
instrument for the study. The questionnaire collected both nominal and ordinal data in a
multiple-choice format. Seven of the seventeen questions collect demographic information
pertinent to the study and the other nine are clinical based.
The researcher initiated the study by first distributing the assessment to potential
participants by sending an email via the intranet system at the host organization. The email
included the informed consent (See Appendix B) and a descriptive request for completing the
assessment.
Method. Evaluation methods include first, organizing the questions by category: six
demographic questions and nine clinical type questions. Assessing demographic data such as

participant age, sex, length of time working at the host organization, and length of time
participants have been a practicing nurse is included in the beginning of the assessment. While
the host organization requires all Case Managers to be Registered Nurses, some nurses may have
worked as licensed or vocational practical nurse (LPN/PN) before becoming RNs, so asking the
question how long a participant has been an RN may not capture the true number of years the RN
has been a practicing nurse. The intention is to have a sum of the years a nurse has worked in the
nursing profession, the question asks that participants combine the years practiced as an LPN/PN
and RN. The instrument gathers the participants’ highest level of nursing education and if the
nurses are Certified Case Managers (CCM) through a certifying organization.
The questionnaire then shifts to clinical questions assessing participant knowledge of
current evidence-based nutritional guidelines HF. The first of the clinical questions uses a Likert
scale asking participants to identify with the level of knowledge they feel they have regarding
evidence-based nutritional guidelines for HF patients. This question asks participants to choose
one of five levels of knowledge about HF nutritional care guidelines, labeled as 1-5 designed for
an easy correlation in the evaluation of results. Choosing “1” indicates the participant is not
familiar with evidence-based nutritional recommendations for CHF patients and does not feel
comfortable talking with a patient about these recommendations. A “2” is a nurse that
understands the basics of CHF nutritional care guidelines but requires the assistance of aids and
tools to assist them in teaching patients. A knowledge level of “3” indicates the participant is
confident in their already present knowledge about nutritional care guidelines and is comfortable
teaching other patients without additional tools or aids. Experts in the area of nutritional
guidelines for CHF patients would select “4”.

Much of the research in the researcher’s literature review focused on the effects of
sodium in heart failure patients and a majority of the guidelines do give some indication of
mg/day of sodium recommendation. Addressing knowledge of the 2013 ACCF/AHA
recommendations, as mg/day sodium intake, is an important component the assessment and is
demonstrated in tables and graphs for visual interpretation. The 2013 ACCF/AHA guidelines are
more specific in addressing the lack of true evidence supporting previous recommended sodium
allowances; the current recommendation by the ACCF/AHA for stage A and B heart failure
patients is adhering to 1500mg of sodium per day. Stage C and D HF have no precise
recommendations in the 2013 guidelines as addressed in the following question in the
questionnaire so demonstrating participant knowledge of this via a table allows for a visual
demonstration (Yancy et al., 2013).
The questionnaire asks participants to relate sodium intake into general concepts such as
daily sodium consumption and types of foods high in sodium. The average sodium intake for the
general population is more than 4,000mg in a day; some examples of less likely sources of
sodium include beets, chicken breast, and baking powder and the method of evaluation of
answers to this question involve presenting the data in a table format (Yancy et al., 2013).
Fluid intake and restriction is another aspect of HF guidelines lacking evidence making
exact recommendations difficult for the ACCF/AHA to endorse. ACCF/AHA does offer that
there is enough evidence supporting that patients living with stage D HF should consume no
more than 1.5 to 2L/day and the questionnaire challenges participant knowledge on this topic
demonstrating responses in a table format as well (Yancy et al., 2013).
ACCF/AHA Heart Failure Guidelines review past research citing JAMA (1996) and the
Journal of Internal Medicine (2001) that elevated blood pressure is a key factor in development

of both preserved and/or reduced ejection fraction heart failure (Levy, Larson, Vasan, Kannel, &
Ho, 1996; Wilhelmsen, Rosengren, Erikkson, & Lappas, 2001; Yancy et al., 2013). ACCF/AHA
states that controlling hypertension with current guidelines lowers the risk of developing heart
failure and cites numerous articles supporting this statement (Levy et al., 1996; Wilhelmsen et
al., 2001; Yancy et al., 2013). The AHA/ACC 2014 guidelines for lifestyle management to
reduce cardiovascular risk support patients consuming a sodium intake of no more than
2400mg/day demonstrating this knowledge in a table with the sodium and fluid assessment
results (Eckel et al., 2014).
Reliability and validity. Establishing validity and reliability of the researcher created
instrument goes beyond the scope of this research project.
Integrity of Data and Data Use
The informed consent explains how the integrity of the data of participants is kept
anonymous throughout all collection and utilization procedures. All participants of research
study will remain anonymous to the researcher via the Qualtrics®
program anonymity feature.
Promise to participants that no use of names or any identifying personal information is collected
in this research study, further protecting the integrity of the participants and the data collected. It
is not possible for the researcher to discover participant identity at any point in time.
Research Design
This research study uses a simple descriptive, quantitative design approach evaluating
data obtained from answers participants provide via the multiple-choice assessment administered
by the researcher via Qualtrics®
. There is no treatment offered by the researcher and the primary
purpose is to examine the relationship among RN CMs and the knowledge deficits that may or
may not exist with this specific population. All participants have received some form of nurse

onboarding education after hiring at the host organization, including a course specific to heart
failure; there have also been two heart failure presentations from the Medical Director in the last
eight years, contributing to available information for RN CMs at the host organization.
Research Methods
The researcher’s project is an objective study designed to demonstrate the level of
knowledge in the area of evidence-based nutritional guidelines for heart failure patients as
RN Case Managers. Through statistical analysis, the researcher evaluates demographic data
such as age, gender, years of experience and level of education. In addition to the
demographic data, the researcher assesses clinical knowledge via multiple-choice questions.
The researcher sent an email out with the request to complete the questionnaire, as well as
with the informed consent, allowing ten calendar days for completion.
Explanation of research method. The researcher uses statistical analysis to evaluate
quantitative data categorically and includes descriptive statistics, evaluating frequency
distribution; measure of central tendency including mean, median and mode; and percent of
distributions (Tappen, 2011). The researcher calculates frequency and percentage
distribution data for all questions in the assessment but is formatting the demographic data
and answers to the clinical questions into separate tables designed in Microsoft Excel®
. The
researcher determines the frequency and percentage distribution of the responses to the self-
evaluation question and representing responses in a pie chart. Calculating the central
tendency for the clinical questions may assist in finding data points worth future
investigation for research by the researcher or the host organization.

Participants
The participants in the study are RNs employed at a large health insurance organization
in St. Louis, MO, recruited via intranet email communication by the researcher. The researcher
will email 85 potential participants with an anticipated number of 30-40 respondents. The
researcher has a professional relationship with potential participants; all currently employed at
the same health insurance organization in St. Louis, MO.
Inclusion criteria required participants be RNs employed as a telephonic CM at the host
organization. Male and females are included in the email requesting participation, there are no
age limitations; no restrictions on level of experience; or type of nursing education when
determining who would be included as participants in the study. Excluding any of the RN CMs
employed at the host organization in a leadership role is a decision of the researcher, avoiding
any missed information or inaccurate information; leadership roles are identified as a team lead,
team lead supervisor, manager, and director of any kind.
Permissions
The host organization does not require IRB approval but the researcher was required to
complete the National Institute of Health online course titled: Protecting Human Research
Participants for both the host organization and WGU IRB approval.
Informed consent (see Appendix B) information is included in the email containing the
link to the survey, the informed consent indicates in writing that clicking the link to the survey
provides consent to participation. The researcher utilizes the Qualtrics®
anonymity feature
keeping participant information private, protecting identity of participants.
Summary
Using responses from active RN CMs responsible for providing current evidence-based

nutritional guideline information to HF patients is an excellent way of incorporating first-
hand evidence-based data into practice. Leadership has the opportunity to utilize the data
collected and outcomes determined by the researcher and this researcher anticipates there
will be a response involving training specific to addressing the gaps in knowledge identified
by the assessment. Leadership at the host organization has indicated the plan to use the
results of the researcher’s study as guiding factors in development of future educational in-
services for RN CMs.

Chapter 4: Findings
Outline of Results
The researcher distributed an online assessment via Qualtrics®
to 85 potential participants
at the host organization on January 24, 2015. The survey remained open until, February 2, 2015,
providing ten calendar days for completion. The results look into demographic data of the
participants creating information depicting a clearer picture of those completing the survey. The
results provide insight to participant awareness of the policy and procedure for locating current
evidence-based information and which information the host organization is using since
information does vary among organizations. The clinical questions look at knowledge of sodium
intake for all stages of HF as well as hypertension, identification of high sodium foods, sodium
intake among the general population, and fluid intake recommendations. The only question that
a majority of participants answered correctly was the question regarding which guidelines the
host organization recognizes as the standard for staff to reference; however, in a previous
question only two respondents of 33 knew where to locate the policy stating which guideline is
currently recognized. The host organization can choose to change which health organization
they choose to adhere to making it important to know where to find the information. A majority
of the nurses did indicate that research indicates nurses are not adequately prepared as HF
educators.
The results are presented first by reviewing varying aspects of demographic data,
evaluation of the nurses self-confidence in the research topic, host organization policy and
procedure for finding current guidelines, and clinical guideline knowledge questions.
Statement of Results
Less than half of the RN CMs participated in the assessment making the data less reliable

since only participant specific variables were included in the evaluation of the data. However,
the results of the assessment do create an opportunity for leadership to collaborate with the
education department to create educational in-services focusing on the identified deficits.
Despite only a small percentage of participants completing the assessment there were still a high
percentage of those participants that answered questions incorrectly or as unsure providing
leadership a place to start.
Analysis of Data
Analysis of demographic data. Researcher divides demographic data into specific areas
and discusses details including: participant ages, sex, role in the organization, level of education,
experience as a nurse and telephonic RN CM, and certification status.
Age, sex, role in organization. In this research project, participants were between the ages
of 20 and 70 years old, most were females, for further analysis of demographic data see Tables 1
and 2 for this information. Despite the clear information on the consent and clear in the
instructions indicating the exclusion of Team Leads and other leadership positions, two
participants indicate they are Team Leads and have completed the assessment either entirely or
partially, the remaining 31 responses were from clinical staff, not in a leadership role, see Table
3 for illustration. The anonymity feature interferes with resolving this discrepancy in data
collection but there seems to be no other discrepancies and data is still relevant. In the future,
researcher would consider a feature that may end the assessment if a participant selects any
option other than intended target.

Table 1. Participant Demographic Data: Age
Age n=
20-40 11
41-60 18
61-70 4
>70 0
Total 33
Note. Participants’ responses to the question, “What is your age range?” from the assessment
found in Appendix A.
Table 2. Participant Demographic Data: Sex
Sex n=
Female 31
Male 2
Total 33
Note. Participants’ responses to the question, “Please indicate if you are male or female.” from
the assessment found in Appendix A.
Table 3. Participant Demographic Data: Role in the Organization
Role in Organization n=
Clinical Staff, non-leadership
role
30
Team Lead 2
Team Lead Supervisor 0
Clinical Manager 0
Total 32
Note. Participants’ responses to the question, “Please indicate your role within the host
organization.” from the assessment found in Appendix A.
Education, experience as a nurse and telephonic RN, and certification.
Further analysis of demographics involves gathering additional participant demographic
information: such as level of education, experience as a nurse, years working as a telephonic
nurse, and whether certified as a Case Manager. Among 33 respondents, 22 (67%) have an
Associate’s Degree in Nursing, while seven (21%) of the nurses have their Bachelors of Science
in Nursing, leaving the less common education levels: Diploma of Nursing, 2 (6%); Masters of
Science in Nursing, 1 (3%); and Nurse Practitioner, 1 (3%).

The years of experience as a nurse varies among participants as shown in Table 5 from less
8 (24%) of nurses with less than ten years of experience to three (9%) of nurses having greater
than 40 years of experience in the profession of nursing.
Table 6 illustrates participant answers assessing the years spent as a telephonic RN Case
Manager with all categories ranking closely. Those being a telephonic Case Manager between 0-
3 years have a frequency and percentage distribution of 9 (27%); 3-6 years, 27% (9); 6-9 years
(8) 24% ; and more than 10 years is at 7 (21%).
The last of the demographic type questions is how many participants are Certified Case
Managers the frequency and percentage distribution; the researcher illustrates this data in Table
7. The requirement at the host organization is that within 2 years of hire the nurse is to be a
Certified as a Case Manager.
Table 4. Participant’s Level of Education in Nursing
Level of Education in Nursing n= %
Associates Degree in Nursing 22 67%
Nursing Diploma 2 6%
Bachelors of Science in Nursing 7 21%
Masters of Science in Nursing 1 3%
Doctorate of Nursing Practice 0 0%
Nurse Practitioner of any
specialty area
1 3%
Total 33 100%
Note. Participants’ responses to the question, “What is your highest level of education associated
directly with the nursing profession?” from the assessment found in Appendix A

Table 5. Participants Years of Experience Working in the Nursing Profession
Years in Nursing Profession n= %
0-10 years 8 24%
11-20 years 11 33%
21-30 years 7 21%
31-40 years 4 12%
40 years 3 9%
Total 33 100%
Note. Participants’ responses to the question, “How long have you been licensed and practicing
in the nursing profession?” from the assessment found in Appendix A.
Table 6. Participant Years of Experience Working as a Telephonic Case Management Nurse
Years of Experience as
Telephonic Case Manager
n= %
0-3 years 9 27%
3-6 years 9 27%
6-9 years 8 24%
10 + years 7 21%
Total 33 100%
Note. Participants’ responses to the question, “How many total years have you worked as a
telephonic Case Manager?” from the assessment found in Appendix A.
Table 7. Certified as Case Manager
Certified Case
Manager
n= %
Yes 19 58%
No 14 42%
Total 33 100%
Note. Participants’ responses to the question “Are you certified as a Case Manager by any
certification organization recognized by the host institution?” from the assessment found in
Appendix A.
Clinical Based Questions. This aspect of the assessment transitions to the clinical
knowledge of the participants. The data collected is not clinically specific initially but becomes
so more later on in the assessment.
Confidence of participants.
The first clinical based question is asking participants to evaluate their confidence
regarding current evidence-based nutritional guidelines for HF patients according to ACCF/AHA

guidelines, Figure 1 demonstrate participant answers to this question. The question asks
participants to choose one of four options the participant identifies with most in the area of HF
evidence-based nutrition. The first of the four choices is rating self as “inexperienced”, or
someone not comfortable talking with a HF patient about evidence-based nutritional guidelines
for HF patients. The second choice is “beginner”, an RN that understands the basics of
evidence-based nutritional guidelines for HF, but uses tools and aids during calls to assist with
discussion. The next option was “confident”, or feeling comfortable teaching patients about
dietary recommendations without the use of tools or aids during calls, this was the most
commonly chosen answer by participants with a 70% percentage distribution. The final option
was “expert”; two of 33 participants view themselves as someone that can educate patients, as
well as, other RNs about evidence-based nutritional guidelines recommendations regarding HF
with confidence.
Figure 1.
Participant Confidence Level in Heart Failure Nutrition
Figure 1- Percentage distribution associated with the question in the assessment located in Appendix A
asking nurses to assess their level of confidence in knowledge of evidence-based nutritional guideline
recommendations for heart failure.
Inexperienced,
0.00%
Beginner, 24.00%
Confident, 70.00%
Expert, 6.00%
Participant Responses
Inexperienced
Beginner
Confident
Expert

Process at host organization. The next two questions address the participant knowledge
of what practice is followed at the host organization identifying any need for reinforcement
education from leadership to ensure participants are aware of the recommended practice.
Host organization’s current clinical guidelines.
The ninth question asks participants where an employee would locate which guidelines are
currently followed at the organization and the answers varied with only two of 34 participants
knowing the correct answer. The correct answer is “Knowledge Library”; this is the intranet
website with the most current clinical guidelines listed for employees to access at any time on
any specific health condition including HF.
The most frequent answers from participants are “Any of the above”, 19 (56%); Milliman
Guidelines, 9 (26%); American Heart Association, 4 (12%). While the other options such as
American College of Cardiology, Heart Failure Society of America, and “none of the above” are
not selected 0 (0%). Leadership may want to address that there is such inconsistency with what
the answer is and what participants perceived it to be.
Clinical guidelines used at host organization.
The researcher asked what guideline recommendations the host organization recognizes as
the standard to reference for evidence-based self-management nutritional recommendations for
HF patients and 41% correctly answered this by selecting the American Heart
Association/American College of Cardiology. The frequency and percentage distribution for the
other choices are as follows American Dietetic Association, 1 (3%); Milliman Guidelines, 8
(24%); Heart Failure Society of America, 0 (0%); Any of the above, 10 (29%); None of the
above 1 (3%). The responses indicate a likely need for additional education by leadership so RN

CMs can seek out education consistently.
Clinical Guideline Questions. The following questions focus primarily on information
based on the current clinical guidelines established by the ACCF/AHA for heart failure and
hypertension.
Sodium intake for stage A and B heart failure. The first clinical knowledge question asks
participants to indicate what the mg/day of sodium the ACCF/AHA currently recommends for
patients with stage A and B heart failure. While the 2009 ACCF/AHA recommendations were
more consistent with the most common participant choice, ≤2000mg/day, the ACCF/AHA
updated the recommendations in 2013, indicating 1500mg/day as an appropriate amount of
sodium per day for patients with stage A and B HF (Gupta et al., 2012; Yancy et al., 2013).
Figure 2 further illustrates participant responses to this question, indicating a need for re-
education of participants.
Figure 2
Sodium Intake for Stage A and B Heart Failure
Answer Response %
1500 mg/day 8 24%
2000 mg/day 16 48%
3000-4000 mg/day 0 0%
No
recommendations,
ask physician for
clarification
3 9%
Unsure 6 18%
Total 33 100%
Figure 2. This figure illustrates frequency and percentage distribution for the question, “What
does the ACCF/AHA use as a guideline for mg of sodium per day for patients with stage A and B
HF patients.”

Sodium intake for stage C and D heart failure. The second clinical knowledge question
addresses sodium intake for patients with stage C or D HF, there are no correct responses to this
question. The 2013 ACCF/AHA Guidelines for the Management of Heart Failure indicate there
is not enough research available to support a specific mg/day recommendation for patients with
stage C or D heart failure (Yancy et al., 2013). Figure 3, highlights an area of interest when
considering topics of discussion educators and/or leaders may want to discuss with participants,
with 19 participants indicating the answer to be 1500mg/day and ten being unsure.
Figure 3. Sodium Intake for Stage C or D Heart Failure
Answer n= %
1500mg/day 19 58%
2000mg/day 2 6%
2500mg/day 0 0%
Insufficient data to
support a specific
mg/day
recommendation
2 6%
3000-4000mg/day 0 0%
Unsure 10 30%
Total 33 100%
Figure 3. This figure illustrates frequency and percentage distribution for the question asking
what stage C and D HF patients should limit sodium to per the ACCF/AHA guidelines.
Average sodium intake of general population. Participants are to identify with what they
thought or knew to be the average sodium intake of the general population and answers varied in
this question. The frequency of the data indicates seven of the 33 participants answering
correctly, that the general population consumes >4000 mg/day, to the most commonly chosen
answer with ten respondents of the 33, indicating 3,000-3,5000 mg of sodium per day is
consumed by the general population (Yancy et al., 2013). Table 4 indicates no one particular
answer to prevail over another while 27% of participants admit to being unsure.

Figure 4
Average Sodium Intake by the General Population
Answer n= %
1500-2000mg 3 9%
2000-2500mg 2 6%
2500-3000mg 2 6%
3000-3500mg 10 30%
>4000mg 7 21%
Unsure 9 27%
Total 33 100%
Figure 4. The responses are to the question asking participants to indicate how many milligrams
of sodium per day the general population averages.
Nurses prepared as educators for heart failure. Asking participants to identify with what
they thought to be true of Nurses being adequately prepared to educate heart failure patients
agrees with research, Nurses are not adequately prepared to educate patients on heart failure.
This question was a simple true/false, trying to help nurses look at what they knew of themselves
perhaps or of other Nurses and their readiness to adequately educate patients, of 33 participants
24 (73%) believed that the research shows that nurses are not adequately prepared, whereas 9
(27%) felt that nurses were adequately prepared to educated about heart failure.
High sodium foods. The researcher asks participants to identify foods high sodium. The
researcher chose the foods listed as options because of the foods the AHA lists as “sneaky”
foods, these foods each are high sodium foods and may be important for RN CMs to be familiar
with these “sneaky” foods (American Heart Association [AHA], 2014). As illustrated in Figure
5, participants seem to lack familiarity with foods that are high in sodium and 82% opt for the
source, ham. None of the 33 admits to being unsure by selecting the choice, unsure, providing
valuable insight for leadership, if they choose to pursue findings from this research study.

Figure 5
High Sodium Foods
Answer n= %
A chicken breast 1 3%
Beets 0 0%
Baking Power 1 3%
Ham 27 82%
All of the above 4 12%
None of the above 0 0%
Unsure 0 0%
Total 33 100%
Figure 5. Frequency and percentage distribution of all answers to the question: “Which of these
foods is considered high sodium?” from the assessment in Appendix A.
Sodium guideline recommendation for hypertension. The sodium intake guideline for
patients diagnosed with hypertension according to the ACCF/AHA is 2,400 mg per day and of
33 participants, four were able to answer this question correctly. Figure 6 demonstrates the
uncertainty participants have on this topic and illustrates the frequency and percentage
distribution of the participant answers. Participants at the host organization work with patients
diagnosed with hypertension that have not yet been diagnosed with HF; if nurses educate patients
on this recommendation perhaps, patients could have a decreased chance of developing HF if
they consume recommended levels of sodium.

Figure 6
Sodium Guidelines for Hypertension Patients
Answer n= %
Consume no more
than 1500 mg/day
9 27%
Consume no more
than 2000mg/day
15 45%
Consume no more
than 2300mg/day
1 3%
Consume no more
than 2400mg/day
4 12%
Consume no more
than 3000-
4000mg/day
0 0%
Unsure 4 12%
Total 33 100%
Figure 6. Responses illustrate frequency and percentage distribution for the question asking
what the sodium guideline, according to the ACCF/AHA, for patients with hypertension.
Fluid intake for advanced heart failure patients. The last question asks participants to
indicate an acceptable amount of liquid an advanced heart failure patient, also known as stage D,
can consume in a 24-hour period, according to the ACCF/AHA. Figure 7 illustrates, 9% of the
33 participants answered this question correctly, providing another education topic for
consideration by leadership. The ACCF/AHA has set a guideline only for patients with stage D
HF at the time of this project, the guideline indicates that 1.5-2 liters of fluid is acceptable and/or
reasonable, other stages are yet to receive an exact recommendation related to conflicting
research (Yancy et al., 2013).

Figure 7
Fluid Restriction for Heart Failure Patients
Answer n= %
1.5-2 gallons/day 2 6%
1-1.5 liters/day 14 42%
1.5-2 liters/day 3 9%
Tailored per doctor
recommendation only
9 27%
2.5 liters/day 0 0%
Unsure 5 15%
Total 33 100%
Figure 7. Responses from participants expressed in frequency and percentage distribution for the question
asking how much fluid is reasonable for an advanced HF patient to consume in a 24-hour period.
Research Question Answer
The research question asks RN Case Managers’ to take an assessment evaluating current
knowledge of evidence-based nutritional guideline recommendations for heart failure patients.
The current knowledge of evidence-based nutritional guideline recommendations for heart
failure patients is determined to be deficient among the RN CMs at the host organization after
analyzing the assessment answers provided by participants.
The questions based on clinical knowledge include asking participants to identify the most
current sodium intake recommendations according to the ACCF/AHA for patients with stage A
and B HF, stage C and D HF, as well hypertension. The number of correct responses versus
incorrect, as demonstrated in Figures 2, 3 and 6, implies an opportunity for re-education of
participants at the host organization. Additional clinical questions include asking participants to
identify the average daily sodium intake by general population; choose high sodium foods from
options listed, and assessing knowledge regarding fluid restriction and HF patients. The number
of correct answers to these questions support researcher’s statement that participant knowledge is
deficient and participants would likely benefit from additional re-education on current evidence-
based nutritional guideline recommendations for HF patients.

Asking participants to evaluate their own level of confidence in the area of current, evidence-
based nutritional guideline recommendations for HF patients using a Likert scale provide
conflicting results. A majority of participants select option 3, indicating confidence in the area
of current evidence-based nutritional guideline recommendations for HF patients, when in fact
participants answered the clinical questions incorrectly or admit to being unsure.
Summary
The outcome of this study concurs with literature reviewed by the researcher, nurses have a
significant role in providing HF education to patients, and ensuring nurses continues their
education on an on-going basis may help ensure that patients are getting the most current
evidence-based guidelines for their condition (Washburn & Hornberger, 2008). Leadership is
responsible for creating a supportive environment for continued learning of nurses responsible
for educating patients (Linton & Prasun, 2013). Leadership may consider using researcher’s
method of first assessing for deficits and then creating an educational in-service to focus on
addressing the identified deficits. Linton & Prasun (2013) indicate it is the right of a patient to
receive the most current evidence-based education; however, if nurses are not aware of the most
current evidence-based practice information it may be challenging for nurses to provide to
patients.

Chapter 5: Discussion and Conclusions
Project Overview
Incorporating evidence-based guidelines into practice brings to the forefront the apparent
lack of research available supporting non-pharmacological approaches to management of heart
failure. In addition to the identified lack of available research for development of guidelines
there is a growing recognition of knowledge deficits among nurses regarding evidence-based
approaches for management of HF (Albert, 2013; Johansson, Fogelberg-Dahm, & Wadensten,
2010; Washburn & Hornberger, 2008). So even if the research available and the organizations
that established guidelines had current, well-supported recommendations the concern that nurses
do not always have access or have time to review the information is a known challenge.
The researcher’s aim in this study is to assess RN Case Managers knowledge of current
evidence-based nutritional guideline recommendations for heart failure patients and if knowledge
deficits are identified work with leadership to ensure they have these results and can act on them,
as they desire. The director of the site was enthusiastic about the researcher’s project and looks
forward to reviewing the results and working with the education department to develop
intervention.
Findings Summary
The limited number of participants presented a concern to the researcher, creating a question
of whether there was an adequate sample to provide relevant results. The researcher sent email
to 85 potential participants and after 10 calendar days was able to have only 33 respondents.
There were six demographic questions, two questions assessing the host organization’s policy
and procedure questions, two questions asking for nurses’ opinions, and the remaining six were
clinical guideline based questions. Responses to the six clinical guideline questions reveal a

clear knowledge deficit with zero of the six questions having a majority of respondents
answering correctly.
How results were obtained. Results were obtained through administration of a survey that
was developed by the researcher via the online survey program, Qualtrics®
.
Possible Solutions
Possible solutions for resolving identified knowledge deficit includes prompt educational in-
services providing nurses with the correct information to the stated questions and any additional
information that is deemed necessary by leadership. Developing educational handouts and
sending via email for RN CMs to reference while becoming familiar with the new current
information. Education department could develop weekly bulletins to send to nurses and
leadership incorporate an allotted, mandatory amount of time into the weekly schedule for nurses
to review these bulletins and any other information.
Another possible solution would be to assign a nurse each month to present a topic on a
specific, current evidence-based guideline to present to staff in team meetings, creating handouts
to distribute to the nurses for future reference. Keeping learning sessions brief allowing nurses’
time to absorb the education before presenting new information.
Implications and Limitations of Project
When reviewing the project as a whole the researcher can identify specific strengths and
weaknesses of the project as well as problems detected while conducting the study.
Acknowledging factors that may have skewed researcher’s findings is important so that in any
future studies these factors can be monitored and taken into consideration when creating the
study.

Strengths. Strengths of this project involve the researcher’s familiarity with what areas
nurses are and are not educated on because of working with the participants. The researcher is
also familiar with patient needs as well as company goals since the researcher and participants
work with the same patient population. The changes to the ACCF/AHA guidelines for
management of HF in 2014 created an area of concern for researcher to investigate since many
fellow colleagues completed nursing school many years ago, and Missouri is not a state that has
required continued education courses for maintaining licensure.
Despite the small percentage of participants, there is still strength in the results of the
study because of the low percentage of those that did participate, who could answer questions
correctly, identifying an obvious knowledge deficit regarding evidence-based nutritional
guideline recommendations for HF patients. Among 85 potential participants, there were 33
participants and often it was incorrect answers provided or unsure answers, this is still a
percentage of RN CMs that would benefit from receiving educational in-services, which is a
strength of the study. The design of the questions allowed researcher to capture data that may be
significant enough for leadership to create an educational intervention.
Weaknesses. Weaknesses of the research project include poor participation rate, perhaps
if the researcher were clearer on the directions and/or consent, that the organization and
leadership had given clearance and supported completion of the survey, participation may have
been greater. Researcher made this revelation after casually investigating the poor response rate
and learned that potential participants chose not to complete because of a fear of making the
company looking bad and a concern of job security if nurses answered incorrectly. Researcher
had not thought of this making this an area to be considered in future studies.

The inability to assess leaderships’ knowledge of the assessment questions (see Appendix
A) I think creates an area of weakness to follow up on. Ideally those in leadership roles would
want to assess their own level of knowledge but the willingness of them to volunteer to take the
assessment and not use resources to look things up would need to be an area of focus. The
leadership in this particular organization are not required to complete clinical based education
thus when an RN CM has a question it is a concern that the information the leader(s) are
providing are subject to the same issues as discussed throughout the research study that those in
clinical roles encounter.
Problems. One problem the researcher detected was not creating a time limit for the
assessment to be completed. This was not something the researcher considered until reviewing
the completed surveys and the time for completion. Upon review of survey completion, 30
participants were able to complete the survey within four to five minutes at the most; however,
three participants took a significantly longer amount of time to complete. This extended time to
complete the survey creates concern of whether the participants did perform some type of search
for answers, instead of following the directions and not performing internet searches or asking
colleagues, and using the “unsure” option if they did not know the answer.
Factors. It seems to be a general consensus among fellow colleagues that despite any
type of survey being anonymous there is a concern that in some way the company would find out
who answered what and then they could be held accountable and punished for this. This is
nothing within the researcher’s control, as the consent was clear that anonymity is absolute and
that it would be impossible for researcher or the host organization for that matter, to identify
which participants answered incorrectly.

Another factor that relates to problems with the researcher’s project is leadership insisting
that completion of the survey occurs on the employee’s own time. The researcher respected the
host organizations request, as it is understandable to not want to utilize company time for an
employee’s schooling; however, this project was designed to assist the host organization in the
area of nurse education and the researcher feels a valuable opportunity was lost. Had the
researcher known the poor response rate, an increased effort of the researcher to work with
leadership to make completion of the survey welcomed and seen as an opportunity among staff
by leadership would have been a focus.
Improvements
Improvements to be made with the researcher’s study is to try to have leadership more
involved with understanding what the MSN student is trying to achieve. The challenge that
researcher encounters is that many in leadership roles at the organization do not have beyond a
two year Associates Degree and are not ready and willing to allow a student to come them and
volunteer to assess the team and develop interventions to improve nurse knowledge and health
outcomes. Replication of research studies is common and as Burns & Grove (2007) discuss
replication is necessary in nursing, as well as, ongoing research to develop the strong evidence-
based practice desired in nursing. Making improvements to previous studies is an important step
in the research process and in this research study, the researcher is able to identify some areas of
further investigation and future changes that may increase participation.
A specific change the researcher would make in the assessment would be the
organization of some of the assessment questions. A specific change to the questionnaire would
be to ask participants to evaluate their level of confidence with their ability to provide current
evidence-based guideline recommendations to heart failure patients, at the beginning of the

clinical question portion of the assessment; and again as the last question. Enabling the feature
where participants cannot go back to change an answer would create a need for the question to
be asked again at the end of the assessment. The researcher would like to see if participants
identify themselves differently after seeing the type of information that clinical guidelines
address
Further investigation. An area that may benefit from additional investigation is
identifying if the level of nursing education and identifying if there is any association or
correlation with incorrect responses and level of education. Another area to consider further
investigation in is determining what interferes with the participants in seeking out the education
on their own to keeping them up to date on evidence-based practice guidelines and not relying on
the employer to provide the necessary education.
It behooves the host organization to begin evaluating RN CM knowledge in other disease
specific conditions regarding evidence-based nutritional guidelines such as diabetes,
cardiovascular disease, and cerebral vascular accidents. In addition to heart failure, diabetes,
stroke, and hypertension guidelines were also recently updated in the last one to two years and
ensuring proper patient education is being delivered is the responsibility of leadership and the
nurses.
While the researcher did intend to exclude those in leadership roles from this study it is
not being implied that it is not just as important for those in leadership to be assessed as it is
often they are referenced to making it imperative they are properly educated. The importance of
timing their assessment would be important because of a possible desire to search for answers to
avoid identifying a knowledge deficit.

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