Managing heart failure in the long-term care setting: nurses' experiences in Ontario, Canada.

Managing Heart Failure in the Long-Term Care Setting Nurses’ Experiences in Ontario, Canada Patricia H. Strachan ▼ Sharon Kaasalainen ▼ Amy Horton ▼ Hellen Jarman ▼ Teresa D’Elia ▼ Mary-Lou Van Der Horst ▼ Ian Newhouse ▼ Mary Lou Kelley ▼ Carrie McAiney ▼ Robert McKelvie ▼ George A. Heckman

Background: Implementation of heart failure guidelines in long-term care (LTC) settings is challenging. Understanding the conditions of nursing practice can improve management, reduce suffering, and prevent hospital admission of LTC residents living with heart failure. Objective: The aim of the study was to understand the experiences of LTC nurses managing care for residents with heart failure. Methods: This was a descriptive qualitative study nested in Phase 2 of a three-phase mixed methods project designed to investigate barriers and solutions to implementing the Canadian Cardiovascular Society heart failure guidelines into LTC homes. Five focus groups totaling 33 nurses working in LTC settings in Ontario, Canada, were audiorecorded, then transcribed verbatim, and entered into NVivo9. A complex adaptive systems framework informed this analysis. Thematic content analysis was conducted by the research team. Triangulation, rigorous discussion, and a search for negative cases were conducted. Data were collected between May and July 2010. Results: Nurses characterized their experiences managing heart failure in relation to many influences on their capacity for decision-making in LTC settings: (a) a reactive versus proactive approach to chronic illness; (b) ability to interpret heart failure signs, symptoms, and acuity; (c) compromised information flow; (d) access to resources; and (e) moral distress. Discussion: Heart failure guideline implementation reflects multiple dynamic influences. Leadership that addresses these factors is required to optimize the conditions of heart failure care and related nursing practice. Key Words: Canada complex adaptive systems heart failure long-term care nursing Nursing Research, September/October 2014, Vol 63, No 5, 357–365

H

eart failure (HF) is a chronic, progressive life-limiting syndrome. In long-term care (LTC) homes, the reported prevalence ranges from 15% to 45% (Daamen, Schols,

Patricia H. Strachan, PhD, RN, is Associate Professor; and Sharon Kaasalainen, PhD, RN, is Associate Professor, School of Nursing, McMaster University, Hamilton, Ontario, Canada.

Amy Horton, MN, RN(EC), is Nurse Practitioner–Primary Health Care, Tutor–Ontario Primary Health Care Nurse Practitioner Program, School of Nursing, McMaster University, Hamilton, Ontario, Canada. Hellen Jarman, RN(EC), BScN, MN, GNC(C), is Nurse Practitioner–Primary Health Care, Geriatric Medicine Consultation Service, ED/Community Outreach Program, St. Mary’s General Hospital, Ontario, Canada. Teresa D’Elia, MA, is Project Coordinator, Institute for Work and Health, Toronto, Ontario, Canada. Mary-Lou Van Der Horst, RN, MScN, MBA, is Assistant Clinical Professor, School of Nursing, McMaster University, Project Consultant Seniors’ Health, Conestoga College and University of Waterloo–Research Institute for Aging– Schlegel Villages, Kitchener, Ontario, Canada. Ian Newhouse, PhD, is Professor, School of Kinesiology, Director of the Centre for Education and Research in Aging and Health, Lakehead University, Thunder Bay, Ontario, Canada. Nursing Research

Jaarsma, & Hamers, 2010), and 1-year mortality exceeds 45% (Caspar & O'Rourke, 2008; Hutt, Elder, Fish, & Min, 2011; van Dijk et al., 2005; Wang, Mouliswar, Denman, & Kleban, 1998). The number of LTC residents with HF is expected to rise (Caspar & O'Rourke, 2008; Daamen et al., 2010; Harrington & Schoenfelder, 2013). In Canada and elsewhere, HF accounts for up to 20% of unplanned transfers of LTC residents to acute Mary Lou Kelley, MSW, PhD, is Lakehead University Research Chair in Palliative Care Professor, School of Social Work and Northern Ontario School of Medicine, Lakehead University, Thunder Bay, Ontario, Canada. Carrie McAiney, PhD, is Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada. Robert McKelvie, MD, PhD, FRCPC, is Professor, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada. George A. Heckman, MD, MSc, FRCPC, is Schlegel Research Chair for Geriatric Medicine, Associate Professor, Research Institute for Aging and School of Public Health and Health Systems, University of Waterloo, Ontario, Canada. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s web site (www.nursingresearchonline.com). DOI: 10.1097/NNR.0000000000000049

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Managing Heart Failure in the Long-Term Care Setting

care hospitals, and those who return to LTC typically experience further decline and many die within months (Canadian Institute for Health Information, 2009; Wang et al., 1998). Many acute care admissions could be prevented and resident suffering minimized if appropriate HF care management protocols were in place in LTC (Gruneir et al., 2010). Despite the prevalence and significance of HF in LTC, scarce rigorous evidence exists about HF-related nursing care in LTC. This article describes a study that explored nurses’ experiences in managing residents with HF in LTC settings—which can serve to inform future initiatives aimed at related system change. The LTC setting is an example of a complex adaptive system (CAS; Anderson, Issel, & McDaniel, 2003; Holden, 2005). It is composed of many parts (complex), LTC nurses and residents adjust their behavior according to unpredictable changes in the environment (adaptive), and all components— human and organizational—form an open, interconnected, and interdependent system. An important factor in the LTC setting that contributes to unpredictability is frailty, a key characteristic of LTC residents that arises from the accumulation with age, of multiple deficits across multiple physiological systems, and which renders affected individuals at increased risk for adverse health events (Bergman et al., 2007; Harkness, Heckman, & McKelvie, 2012). LTC residents with HF are particularly frail. Considering nurses’ capacities to engage in HF-related care through a CAS lens offers an opportunity to understand the nursing context in new and instructive ways (Holden, 2005) and to subsequently inform interventions aimed at improving HF care for this frail population. In Canada, LTC nurses (i.e., registered nurses [RNs], registered practical nurses [RPNs]) are primarily responsible for the daily management and care coordination for residents. Although the complexity of resident care in LTC has been increasing, the skill mix of nurses has decreased over the past decade—resulting in higher RN-to-resident ratios (Pelletier, 2001). In fact, the more skilled nurses (RNs) have gradually been replaced with less skilled nurses (RPNs), creating many challenges for providing comprehensive and complex care, particularly for residents with HF (McGillis Hall, 2003). Increasing workplace demands have made LTC nurses prone to burnout (Anderson, Corazzini, & McDaniel, 2004; McGilton, Tourangeau, Kavcic, & Wodchis, 2013)—particularly when communication and administrative support are poor (Anderson et al., 2004). Our research has shown that LTC nurses function both as clinical leaders and middle managers, straddling the complex terrain between residents and families, multiple care providers, physicians, community, and hospitals while ensuring compliance with extensive LTC-related legislation (Marcella et al., 2012). Nursing responsibilities for residents with HF generally include assessment, implementation and coordination of residents’ care needs, and coordination of the interprofessional care team, including the direction of other nurses and unregulated caregivers. Unregulated caregivers include healthcare aides


and personal support workers whose practice is not regulated by professional licensing bodies.

Parent Study The main study in which this analysis is nested was focused on assessing barriers and solutions to improving HF management in LTC homes (Newhouse et al., 2012). We have previously reported an analysis of the interprofessional (between role) barriers to HF LTC based on application of an interprofessional model to the transcripts of residents and families, physicians, nurses, and personal support workers (Newhouse et al., 2012). Communication breakdown between all stakeholders and between LTC and institutional settings was identified as the dominant interprofessional barrier to HF care; this was attributed to interpersonal and organizational factors that could damage or facilitate relationships at all levels. We then analyzed the data to identify perspectives about the impact of organizational context on HF management. Rigid care routines, increasing reliance on unregulated care providers, hierarchical communication patterns, overregulation of LTC by government, and lack of human and diagnostic resources were viewed as inhibiting appropriate HF care (Marcella et al., 2012). Both previous reports particularly highlighted the perspectives of unregulated care providers. In this article, we report on a discipline-specific analysis that was subsequently undertaken to focus solely on nurses because the specifics of their experiences and the implications for nursing practice had not been explicated in the previous papers.

Objective The objective of this analysis was to explore LTC nurses’ experiences in managing HF. The analysis and application of CAS informs the development and integration of HF-specific interventions related to nursing care processes aimed to improve residents’ outcomes.

METHODS Design This was a descriptive qualitative study nested in Phase 2 of a three-phase mixed methods research protocol to investigate barriers and solutions to the implementation of HF management processes based on the Canadian Cardiovascular Society HF guidelines into the LTC setting (Arnold et al., 2006; McKelvie et al., 2013). A complete description of the main study has been published (Newhouse et al., 2012). The study received ethics approval from the University of Waterloo, McMaster University, and Lakehead University.

Participants Focus group participants were recruited from four mediumsized LTC homes (from 96 to 251 residents) in Ontario, Canada, between May and July 2010. These sites represented variations


Nursing Research • September/October 2014 • Volume 63 • No. 5

in setting (northern and southern geographies), university affiliation, and ownership (public or private ownership, and profit or not-for-profit; Newhouse et al., 2012, p.4)—characteristics shown relevant to HF management and outcomes (Coburn, Keith, & Bolda, 2002; Hutt et al., 2011; McGrail, McGregor, Cohen, Tate, & Ronald, 2007; Weech-Maldonado, MeretHanke, Neff, & Mor, 2004). None of these sites had a formal HF management program. Site directors selected participating nurses based on their availability to attend a focus group. Focus groups were facilitated by a moderator using a semistructured interview guide. Questions were developed by an expert multidisciplinary and interprofessional research team and informed by knowledge of HF guidelines and scopes of practice for RNs, RPNs, and NPs. The interviews began with the question, “Tell me about your role in managing residents with HF.” Questions focused on nurses’ experiences in managing acute, chronic, and/or advanced HF, including their perceptions about current HF management practices and facilitators, and challenges to implementing HF care processes informed by guidelines. A trained interviewer facilitated the focus groups. Focus groups ranged from 1 to 2 hours in length, were digitally recorded, and transcribed verbatim.

Data Analysis All nurse transcripts were reviewed for transcription accuracy by two coding analysts (AH, HJ) and entered into NVivo9. We conducted manifest content analysis on all transcripts (Elo & Kyngäs, 2008; Patton, 2002; Sandelowski, 2000). All transcripts were read by the three members of the primary coding team (AH, HJ, PS). AH and HJ were nurse practitioners (NPs) with HF knowledge and experience and enrolled in a graduate nursing program; they had not been part of any previous analysis and were new to the data. On the basis of the independent reading of transcripts by the analyst team, an initial code book was devised to guide the subsequent analysis. Transcripts were subsequently read line by line and inductively coded by AH and HJ. PS oversaw that process and encouraged critical discussion of coding notes and differences arising in coding over four face-to-face meetings. The primary analysis team met regularly to discuss codes and the “fit” of the data into the initial codebook, to identify new codes, to collapse and/or relabel and challenge codes, and to define emerging themes. We searched for negative cases and between-group (RN, RPN, NP) and between-site differences. A secondary analysis team composed of three coinvestigators (PS, SK, CM) reviewed and challenged the coding decisions and analysis. Consensus regarding final results was achieved following rigorous review and discussion. Finally, five subthemes were identified that related to one overarching theme. An audit trail was maintained to describe all stages and decisions involved in the analysis. (See Figure, Supplemental Digital Content 1, which outlines the analysis process, http://links.lww.com/NRES/A125.)


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RESULTS Participants As shown in Table 1, a total of 33 nurses participated in five focus groups: 14 RNs, 14 RPNs, and 5 NPs—three of whom were directors of care for the LTC home. Five to nine nurses participated in each focus group.

Capacity for HF-Related Decision-Making The overarching theme that characterized nurses’ experiences in managing the care of LTC residents with HF was their capacity for HF-related decision-making. Nurses framed their experience in managing HF in relation to making care decisions. As shown in Figure 1, they described significant influences on decision-making capacity affecting their ability to manage residents as follows: (a) a reactive versus proactive approach to chronic illness; (b) their ability to interpret HF signs, symptoms, and acuity; (c) compromised information flow; (d) access to resources available to manage resident needs; and (e) moral distress.

Reactive Versus Proactive Approach to Chronic Conditions Nurses’ experiences fell along a continuum from a proactive to reactive approach to care. A proactive approach was characterized by residents being medically optimized according to HF guidelines (Arnold et al., 2006; McKelvie et al., 2013) and monitored for signs of decompensation—with early interventions to prevent and or manage an exacerbation. A reactive approach was characterized by a predominant focus on responding to acute HF-related decompensation. In one home with a physician HF champion, nurses described moving to more proactive HF management; this was markedly different from the other study settings in which a more reactive approach was the norm. This proactive shift resulted in nurses having improved confidence and ability to monitor and manage HF-related issues. One RN described how they had implemented daily and weekly weight monitoring records that assisted them to manage HF: . . .in-house and the assessments are right on and we're catching it (acute HF) a lot quicker. I'm not thinking of TABLE 1. Focus Group Characteristics Participant numbers Ontario Location

Composition

Northern

RNs RPNs RNs Mixed NPs

Southern

RPN

RN

NP

0 8 0 6 0

5 0 6 3 0

0 0 0 0 5

Note. NP = nurse practitioner; RN = registered nurse; RPN = registered practical nurse.


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FIGURE 1. Factors contributing to heart failure-related decision-making in long-term care settings.

too many examples where we've sent people to hospital in the last year. Our follow up is a lot longer and kind of immediate. We have a lot more chest assessments. (RN)

Proactive care included ensuring a HF diagnosis was communicated to caregivers at the point of care, pharmacotherapy was optimized, energy conservation and compression stockings were promoted, more frequent monitoring and physician consultation were implemented, and advance directives were completed. The absence of an established HF diagnosis on the LTC health record was a significant barrier to providing appropriate care and recognizing HF signs and symptoms. Nurses said residents were frequently admitted with multiple lists of different and/or conflicting medical diagnoses and medications; if HF was not clearly communicated and recorded, cues to enact proactive management would be missed and HFrelated care would not be implemented. Those who adopted a proactive approach said this usually consisted of closely monitoring cues over a few days that indicated a possible change, then responding to alter care and/or consult with the physician. Some nurses expressed discomfort with interventions such as salt and fluid management, weight monitoring, and parenteral diuretics—which they perceived as too “aggressive.” Whether or not a proactive approach had been taken, all nurses described that episodes of acute cardiac decompensation would usually result in a decision to (a) transfer to the emergency department (ED) or (b) seek an order for palliative care.

more confident and knowledgeable about HF assessment and care. One NP said that HF-related changes in elderly residents were sometimes mistaken by others as age related and, subsequently, judged as insignificant. RNs and RPNs described that HF-related clinical reasoning challenges related to their varying abilities and confidence to recognize and respond to subtle signs of worsening HF, particularly when situations were complicated by residents’ other complex, chronic comorbidities and frailty. This affected their care decisions and their direction of regulated and unregulated caregivers. HF exacerbations were often described as coming on quickly, although some nurses said that, in retrospect, subtle symptoms noted in the weeks preceding a HF crisis were actually indicators of impending decline, but not interpreted as such nor acted upon: “Like sometimes you don’t pick up on warning signs right away. If she had edema before, you wouldn’t really take into consideration…no red flag would go up because she does (always) have edema” (RPN). When confidence and resources were lacking to adequately care for acute HF decompensation, nurses initiated transfer to the ED using specific transfer protocols: If somebody is making [grunting noises] that wet bubble sounds, they're going in (to ED); because I can't tell you if it's cardiac, (or) if it's respiratory. I can tell you they're failing. I can tell you their colour is poor. We've got an 02 sat. We've got a blood pressure cuff. We've got a stethoscope. (RN)

Ability to Interpret Signs, Symptoms, and Acuity of HF Most LTC nurses could accurately describe classic HF symptoms; however, subtle or atypical HF signs, common in frail individuals, were often mistakenly attributed to other disease processes. There was variability among RN and RPN understanding of the HF syndrome and deficiencies in self-efficacy about relevant physical assessment skills (such as chest assessment) that lie within the scope of nursing practice. NPs were

One NP said that HF-related changes in elderly residents were sometimes mistaken by others as age related and, subsequently, judged as insignificant.



Nurses perceived that inconsistencies existed between institutional policies for care decisions and the scopes of practice for which they were licensed. This partly contributed to RNs and RPNs not fully operationalizing their potential to implement care decisions for HF management, instead relying on doctor’s orders for interventions such as vital signs and monitoring weights. NPs—in their expanded role and scope of practice—expressed more confidence, autonomy, and satisfaction with managing HF. Many nurses relied on physicians for HF care decisions; yet, physicians who were unfamiliar with HF guidelines and/or were not identified as the “most responsible physician” were sometimes hesitant to support informed nursing requests aimed at avoiding decompensation, such as diuretic administration to relieve dyspnea.

Compromised Information Flow Information flow between nurses, other LTC staff, family members, and external organizations was characterized as insufficient; this affected the capacity of nurses to make HF-related management decisions. Communication with hospitals about a resident’s health status, medications, or lab results was described as “nonexistent,” “very poor,” and “disjointed”—with time lost “searching for information” or paperwork that is “lost somewhere in transit.” Paradoxically, LTC nurses had to provide significant information to the hospital when transferring patients. Yet, frequently when hospitalized LTC residents were discharged with no supporting documentation, nurses had to rely on family caregivers to relay information to formulate an updated care plan. All nurses from the study sites perceived the highly regulated structure of LTC as negatively impacting information flow and, subsequently, their decision-making autonomy. Nurses were increasingly removed from direct care. This necessitated a reliance on unregulated care providers with little or no understanding of HF to accurately identify when residents were experiencing HF-related difficulties and effectively communicate this information.

Access to Resources Nurses’ access to specific resources significantly affected the timeliness, scope, and nature of the decisions nurses said they can make with regard to HF management. For instance, most Canadian LTC homes do not have access to onsite laboratory testing or diagnostic imaging; the cost of using mobile diagnostic services had to be considered in relation to the perceived urgency for results. Available resources could include an advance care plan, an emergency medication kit, and access to a supportive on-call physician. Standing orders or medical directives assisted nurses to engage in timely and appropriate decisionmaking regarding resident treatment. All nurses relied on the resident’s care plan to guide clinical decisions. These resources were vital to nurses actively engaging in HF-related clinical decision-making. Nurses appreciated—but did not always have


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access to—physicians who were both up to date in HF management and familiar with the resident. Some LTC facilities had medical directives in place for emergency medication boxes (e.g., intramuscular or oral diuretics, anxiolytics, and narcotics) and standing orders for oxygen that allowed nurses to work maximally within their scopes of practice. Others said they needed more resources: . . .the right medications on hand. The right treatments on hand. Having protocols set up for those treatments. Standing orders, like Lasix IM (intramuscular), it's there. You just go get it and give it. Standing orders for oxygen for example, you don't have to be calling in with that delay and we can just, we can just initiate it. (RN)

However, even when supplementary oxygen was available and was deemed necessary, it was not easily implemented as this nurse described: We have residents who will fluctuate with their oxygen needs and they may not meet the (government) criteria to get funded for the (LTC) home oxygen. So, the (LTC) homes down here have a tank or two that they will kind of distribute as needed. But if you have someone who is declining in their congestive heart failure and they are requiring it on a more ongoing basis but they don't meet the requirements for the home O2 it becomes a battle whether they are going to get the oxygen depending on the nurse (and his/her decision). (RN)

Moral Distress Focus group transcripts were replete with examples of moral distress arising from organizational and social goal conflicts that nurses experienced in the provision of care that affected their capacity to make HF-related decisions. These conflicts were manifested when resources (human or material) were scarce, strict policies and structures impeded person-focused care, differences existed between family and resident wishes, and when the goals of care were unclear. Changing health system expectations about the level of care in an LTC home also created conflicts that generated moral distress. Some nurses perceived HF care was overmedicalized in LTC, likening it to a hospital medical floor where care was considered more aggressive: They want to send people back (from hospital) and then we are told by the LHINs (regional health authority), take more IVs. You know, I wouldn't be surprised if they wanted us to start doing dialysis, you know, there is more and more going on in the long-term care homes, but they're not looking at staffing levels to look at those kind of people. If they want us to handle those more acute people, we can do it, and we believe that people need to be in their home. But we need a lot more staffing than what we've got. (RN)


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The benefit to the resident of optimizing cardiac pharmacotherapy and the intensity of monitoring in LTC were questioned by some nurses as overly invasive: I feel we're taking their blood pressure all the time. And I think if they're at home, would they be getting their blood pressure taken, or just when they go to the doctor? I feel like it's a little too much. (RPN)

Paradoxically, nurses were conflicted about the value of sending residents to acute care for acute decompensation, rather than keeping them in the LTC home where they perceived care as more person centered. Nurses believed that hospitals were neither sensitive nor attentive to the needs of older adults, giving many examples in which residents returned from an exacerbation of HF with other needs unmet: Many of our residents are very old and you know, in years past it was always thought that the hospital was the place to go when you get sick. You know, it's not the place to go if you get sick, coming from long-term care it's not you know. For acute situations fine, but not for management of long-term care residents. I don't think they're well managed in hospital frankly. I think we can do as good a job. (RN)

Although nurses recognized the value for residents to get evidence-informed HF care, they also worried about the negative effect on LTC staff and residents, when even the implementation of seemingly innocuous HF care recommendations would interfere with workloads and subsequently other LTC routines: We're adding daily weights or weekly weights, that's a huge time factor, time commitment to the on-floor staff to do those weights'we're wanting to do more weights, but it puts a real burden on the system and on the staff providing the care. (RN)

Nurses were concerned about how to manage the tension between the dilemma of maintaining good work conditions and staff relationships and providing safe, effective, and genuine personcentered care. Every nurse reluctantly accepted that, although it is not possible to know everything about all residents under their care, they are responsible for directing care and managing HF emergencies. Staff workloads were described as “overwhelming”; the need to attend to administrative functions competed with needs to assess residents and attend educational sessions. It was observed that HF guidelines were often construed as conflicting with residents’ and families’ choices. Examples included high-sodium treats that are contraindicated in HF, yet enjoyed by residents, or the right to refuse recommended care, such as transfer to hospital. These goal conflicts manifested most dramatically in acute HF exacerbations in which residents became clinically unstable, distressed, and dyspneic. Nurses said they were “frustrated” and “helpless” and sometimes felt there was “nothing we could do.” At these times, LTC home goals to maintain fiscal responsibility through


resource management could conflict with nursing and resident goals to relieve suffering. For example, managing HF symptoms could create distressing situations for nursing staff and undermine nursing decisions, particularly if such care involved use of scarce resources, such as supplementary oxygen. An NP recounted such an incident: “The Director of Care was just berating this nurse because she gave the patient oxygen overnight and it was going to cost and who did she check with, was she sure they really needed it?” Thus, even when implementing appropriate HF interventions, nurses were sometimes left conflicted about how to best resolve conflicts between use of available resources and relief of suffering.

DISCUSSION Our findings illuminate several interrelated factors and conditions that influence nursing management of HF. They are consistent with and expand on previous findings about barriers and facilitators to guideline use in LTC (Colón-Emeric et al., 2007) and specifically contextualize the issues to HF. Successful integration of HF guidelines into LTC will be partially contingent upon addressing the influences on nurses’ capacities to make HF-related decisions in frail residents. Nurses have described that the competing interests of various stakeholders make HF-specific care a challenge to integrate; constraining LTC legislation, professional licensing boundaries (e.g., perceived scope of practice issues), and funding restrictions (e.g., staffing mix, limits to home oxygen) influenced their ability to enact care. Nurses clearly required more HF-specific knowledge, timely access to information, and opportunities for dialogue with clinicians in other areas of the system. The authority and resources to enact decisions within their scopes of practice so that they could adapt to changing clinical contexts and take clinical action for more appropriate HF care were also needed. Nurses’ descriptions reflect the need for reconciliation of organizational, social, and moral goal conflicts. This is necessary for sensemaking about the appropriate integration of guidelines into the LTC context and to create optimal circumstances for nurses to engage in individualized HF-specific care decisions. Sensemaking, the ability to recognize patterns and derive meaning (Weick, 1995), is a central concept of CAS. LTC nurses must have the tools (knowledge of HF, relational and technical skill, access to the resident’s medical information and human, organizational, and technical resources, and authority on the interprofessional team) to make sense of potential and developing patterns in residents with HF. Only then can they engage in the necessary clinical reasoning that affords appropriate and compassionate HF-specific care. For this to occur, nurses must understand chronic HF management and reconcile how HF guidelines and a proactive approach to care are relevant for frail LTC residents. Such an approach is neither possible nor likely if it is undertaken by individual nurses; it must be adopted and supported by the system at-large.



Nurses’ concerns reflected they need opportunities to explore how guideline implementation can be consistent with contemporary models of LTC. Culture change models in LTC focus less on medical models of care and more on social models of living (Koren, 2010). Person-centered approaches, where staff, residents, and families work as partners in decision-making about care (Edvardsson, Varrailhon, & Edvardsson, 2014; Kitwood, 1997; Ruggiano & Edvardsson, 2013), are being frequently adopted. It was apparent that some nurses perceived HF-specific interventions as aggressive and inherently inconsistent with a person-centered approach. In fact, integration of HF guidelines with a palliative approach is consistent with the principles of person-centered care (Canadian Hospice Palliative Care Association, 2012); residents and/or their substitute decision-makers must have opportunities to understand how guideline-informed care could lead to better outcomes, such as increased comfort and decreased hospitalization. Specifically, the application of many HF interventions to frail seniors, including the use of medications such as angiotensin-converting enzyme inhibitors, avoidance of excessive sodium intake, and the titration of diuretic doses according to patient weight, is endorsed by guideline documents (Arnold et al., 2006). Evidence exists to suggest that these interventions may improve outcomes of relevance to frail seniors, such as mood, function, and cognition (Harkness et al., 2012). The need to discuss and resolve this practice tension at organizational and individual levels is urgent (Buck & Hoyt Zambroski, 2012). This is also consistent with calls for increased communication about end of life in HF care (Barclay, Momen, Case-Upton, Kuhn, & Smith 2011). Supporting staff in ways that reduce their work-related and moral distress in relation to these issues will contribute to a person-centered and caring LTC environment (Orrung Wallin, Jakobsson, & Edberg, 2013). Nurses’ decision-making became challenging when a resident’s condition deteriorated. From a complexity science perspective, this can be understood as the system migrating toward disequilibrium, self-organizing to meet demands of the situation, and resulting in a nursing response (Eoyang, 2009; Holden, 2005). Whether these response patterns are positive or negative for the resident will depend, to a great extent, on whether the care system promotes the flow of information and energy between the internal and external factors identified in this study (Caspar, O’Rourke, & Gutman, 2009; Cilliers, 1998; Eoyang, 2009; Zimmerman, Lindberg, & Plsek, 2008). This information flow has been referred to as transformative exchange (Olson & Eoyang, 2001), when that exchange is impoverished, as was commonly reported in this study, the patterns that emerge may be suboptimal (Cilliers, 1998). For the resident, this may mean more frequent exacerbations and unnecessary suffering; for the nurse, feelings of moral distress, frustration, and burnout. Because LTC nurses are often furthest from the point of care and rely heavily on unregulated care providers for information, it is imperative that information flow is optimal between all agents. As we,


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and others, have found, the hierarchical and resource poor nature of many LTC settings contributes to ineffective information flow between caregivers and institutions—even in institutions that have adopted a person-centered approach (Caspar et al., 2009; Colón-Emeric et al., 2006, 2007). To increase nurses’ capacities to make proactive person-centered care decisions, empowerment of healthcare aides is a necessary precondition for effective information flow that promotes the emergence of favorable care conditions. It is essential that nurses can give the necessary direction and support to these caregivers. However, consistent with the dynamic and sometimes unpredictable nature of CAS, in many LTC settings, even a nurse with the knowledge and authority to implement interventions— such as regular weights—may contribute to unintended consequences to other residents. Nurses described that (even) successful integration of weights into regular care could result in added burden to staff and may lead to other care not being implemented. We are cautioned to avoid applying a mechanistic model of human and organizational systems leading to a focus on a single factor, such as weights, to rectify a care deficiency (Anderson et al., 2003, 2004; Capra, 1996; Plsek & Greenhalgh, 2001; Zimmerman et al., 2008). The challenge of implementing daily weights is an elegant example of the goal conflicts that can occur in a CAS; it also demonstrates how a small change in the system may lead to unintended consequences. The implementation of new HF initiatives should include anticipation of the potential consequences of dynamic interactions with other components in the system. Thus, interventions aimed at increasing nurses’ HF-related decision-making must consider the potential for possible unintended effects on other care-related activities. Without this approach, the implementation of HF guidelines in the system could exacerbate organizational goal conflicts and perpetuate moral distress among nurses; it is also possible that a small change involving the increase of information flow may also result in a positive and significant change. To address such dilemmas—and consistent with our research approach and person-centered care—inviting all LTC staff, volunteers, residents, and families to develop a solution could generate some innovative ideas that could improve care. This requires managerial leadership that is open to and effectively promotes such an approach (Gibson & Barsade, 2003). Leadership in LTC that fosters creativity and cognitive diversity from those involved (from policymakers, management, and nurses to housekeeping staff and resident families) is associated with high-performing LTC homes (Forbes-Thompson, Leiker, & Bleich, 2007). Such an approach could also help nurses to maximize their scope of practice. For instance, some interventions, such as weight monitoring, do not require a doctor’s order and are part of the HF self-care management that is encouraged in the home setting as part of chronic disease management and clearly falls within the scope of nursing practice. This proactive and basic assessment is one of the key interventions to prevent exacerbations and related suffering (McKelvie et al., 2013).


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Findings support calls for strategies that increase information flow, build relationships, increase connections, and reject a top-down imposition of changes (Anderson et al., 2003; Bellot, 2012; Colón-Emeric et al., 2006). For nurses to maximize their practice capacity, relationships must exist that are built on mutual trust, understanding, and a sharing of collective knowledge (Brown Wilson, 2009; McCormack et al., 2002). The creation of and system support for continuing educational opportunities are also essential to shift to a proactive, personcentered approach that is informed by HF guidelines.

Limitations This study was designed to maximize participant contributions and decrease real and perceived power differentials among nursing staff (RPNs, RNs, NPs) and between interviewers and participants. It is possible that, because of the focus group approach, perceived power imbalances among participants may have influenced the discussion that some insights and experiences were not shared and/or contributions were worded in a way participants’ thought was expected. Although we did analyze for between-nurse group differences, individual participant data that may impact reported experiences were not collected.

Conclusion Interrelated and interdependent issues are keys to the decisionmaking capacity of nurses about HF in LTC settings. Integrating HF guidelines requires an understanding of these issues and a thoughtful examination of their fit with a person-centered approach to care. Accepted for publication May 20, 2014. The authors acknowledge that this study was funded by an unrestricted grant-in-aid from the Heart and Stroke Foundation of Ontario (NA-6811, Principle Investigator Dr. Heckman). Dr. Heckman also received support through the Schlegel Research Institute for Aging Chair in Geriatric Medicine and the E. J. Moran Campbell Internal Career Research Award from the Department of Medicine at McMaster University. The authors also gratefully acknowledge the participation of long-term care homes and their staff in this study. The authors have no conflicts of interest to report. Corresponding author: George A. Heckman, MD, MSc, FRCPC, Research Institute for Aging–University of Waterloo, BMH 3734, 200 University Avenue West, Waterloo, ON, Canada N2L 3G1 (e-mail: [email protected]).

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