Home care nurse management of patients with chronic cardiac disease has focused on three core elements: 1) education of patient and family (risk factors, medications and compliance, diet), 2) symptom monitoring (first by the nurse and then by the patient), and 3) close communication with health care providers. Advances in technology and increased use of the Internet by lay people make technology-based interventional research aimed at increasing patient self-management skills, improving quality of life and avoiding emergent hospitalizations possible.
Research in this area has taken advantage of available technology to support cardiac patients by addressing one or a combination of the described elements. Trans-telephonic monitoring,12
two-way telemedicine audiovisual system,13,14
and special-purpose monitoring devices like the HealthBuddy15
addressed symptom monitoring. Clinically meaningful and statistically significant improvement in blood pressure levels resulted from a one-year exposure to usual care that was enhanced by telephonic monitoring; however, the technological intervention stood separate from the clinical practice.16,17
Home monitoring also led to improved energy expenditures among older adults with high disease burden following cardiac surgery. The Med-eMonitor which prompted patients with congestive heart failure about diet, activity, medication taking, and requested answers for questions about symptoms, blood pressure and weight18
addressed both monitoring and education.
The first HeartCare study pulled together these three threads. We provided Internet-based information and support for patients experiencing the full recovery trajectory following coronary artery bypass graft surgery.19
Similarly, Westlake and colleagues20
demonstrated the effects of a Web-based education, including email capability to a clinical nurse specialist and other study participants, links to Web video content. This study, HeartCare II, builds on the successes of HeartCare I and other pioneers in this field, this time weaving the threads of education, symptom monitoring and communication to intuitive interactive web-based tools designed to help nurses teach patients to learn to manage their health. The result was a new model of nursing care: TEP.
Using technology to engage patients and nurse professionals in chronic cardiac disease management is challenging. For patients it requires developing a joint understanding of what self-management actually means through the trajectory of the disease process, not simply when the nurse is present.21
For nurses, the introduction and integration of technology requires a different way of thinking about the delivery of nursing care. Many home care nurses hold the belief that it is the “relational aspects of the nurse-patient relationship that hold the greatest significance for both nurses and elderly people…the therapeutic value of visits reaffirm their core values”22
( p.86). Introducing information technology into this interpersonally rich dyadic relationship proved challenging.
We report on the effects of this novel practice model, TEP, on patient self-management, quality of life, health status, satisfaction with nursing care, and unplanned service use. The intention of this project was not to prescribe how the technology should be used, but rather to give the home care nurse a tool box that could be implemented specific to the patient and context, without disrupting established workflow or the relational aspects of care. As a result, there was no uniform exposure or dose, but rather a wide range of manifestations of use dependent on the context and on mental models of both patient and nurse.